HomeMy WebLinkAbout0169 CAPES TRAIL - Health 169 Capes Trail
West Barnstable
A= 088 — 007 - 001
FROM :down cape engineering inc FAX NO. :15083629880 Sep. 28 2009 09:19AM P1
Town of Barnstable
lteplato ry Services
i Thomas F. Geiler,ADArectolr
a f1AHN&rAL9L3,
200 tVR:at a Strect,11ya9u nas, MA 02601
Of-fice, .508-8624644 Fait SOQ-79Q-G3i14
Insta.l➢e r&.:Qt,t n±1r.CTerfi icmtw.0.R Form
ID�te: Sewage Pennait if 2,00l `ill Aq.5cssur's Map\ParcW/0 u- 00/Ply/
l�es>i ,per: pV)V1, lg Installer: �0 /P ��a�
mo
Ors 6 "l ��� _! was issued a per.tiv.t to install a
(date) (installer)
septic system W. A e tiI` V-,2 based on a design drawn by
(address)
0417 e dated. CJ
` ,.1 ccrtif�, that the septic system.referenced above was installed substantially aecordinF to
the design, which may incltade miaaor approved cl:tangcs such as latel-al reioCation of the
distribution box a:Lld/or septic tank.
1 certify that the septic system reforenced above was instaJ.led with rmjor changcs (i.e.
Prea,tet than 10' lateral rclucaiiurn ut'the SAS or any vertical relocation of Lilly Component
ol'the septic system)bur in LICCOTdan.ce with Statc &. Lot;Ltl Regulations, 1°l.an revision or
certi fled as-huilt by designer to follow.
f
OF M
` ? UANIFt.A.\ r
(Irista s Signature)
CIVIL, en
ff �fi 7 TY�EiU,y�v
L
(Designer's Signature) (Affix Desi.gizer's Stamp Mrc)
e°L9;A ;m: IPts F'iJlifal__TO tiAldRTSLAl$,9,1_ 11; ILIC ITEALTH DIVBSIDN. _ e-3 oW 'EtCA'l'E, OF
a-,OIVTD LIANCIE, Vb 13, NOT BF T.&STTE D iTN':[1f ltlBTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNS-TABLE PUBLIC HFAi,TH k1:mslori . 'A'1lL�1VA�Xl�t1.
Q: I lca!th/septic/I)e,,iAitce Uertif:ication Form 3-26-04.d9c
TOWN OF BA RNSTABLE
Y ^
LOCATION � (a� r/ o _ SEWAGE#ZOO?
VILLAGE c�'/rl,y �`� ASSESSOR'S MAP&PARCEL —9'X, �D7ij
INSTALLER'S NAME&PHONE NO. �/� � > ,p6�y 77/�W
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �/-✓�'�,al, ^��/� (size)
NO.OF BEDROOMS ee_1a �S(��` plwr ; l/
OWNER is�nph uv► 7r �`I I
PERMIT DATE: !��/ D COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private Water Supply Well and Leaching Facility(if any wells exist
on site or within 200 feet of leaching facility) feet
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet of leaching facility). feet
FURNISHED BY
._
� � .. ��6
o
Fy .��.
m — ��
��
[ ♦I l
No. �O� �"L l Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r�
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippYtcation for XDiopo al *paem Construction Vermtt
Application for a Permit to Construct( ) Repair(V/) Upgrade( ) Abandon( ) ❑Complete System LJ Individual Components
Location Address or Lot No. 5 / �� Owner's ame,Address,and Tel No.
Assessor's Map/Parcel W I B T//S a
Instal er's Name,Address,and Tel No. Designer's Name,Address and Tel.No.
r`°� i C°�s�`' Z /�' �J®can Ca�� �� • �dZ- �yJ
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder
Other Type of Building �$I pr/c No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) rJ gpd Design flow provided 1 0 gpd
Plan Date Z 69 Number of sheets Revision Date
Title f & S 7°—1 0- „ W/
Size of Septic Tank Type of S.A.S. q "
Description of Soil TT A9Z/L9�' Z �
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boa d of It
Signed Date
Application Approved by < s+ Date 9/// ")1J
Application Disapproved by: Date
for the following reasons
Permit No. O 2 Date Issued 2 DOj
--- — -- ------._. �—=_ ----- - - --- - - - --------
No. ZAO� � / Fee
�.
O THE COMMNWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
RpPlication for--Mi5poga1-*p5tem Cow6tructiou Permit
1�4'Application for a Permit to Construct( ) Repair(V� Upgrade( ) Abandon_(. ) ❑ Complete System I r I Individual Components
Location Address or Lot No. C, / �d Owner's ame,Address,and Tel.No.
ssessor's Map/Parcel 8a►f�51-6146 le � 4y
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms �3 Lot Size sq. ft. Garbage Grinder ( �
Other Type of Building /5 G,5/Y)OeC e No.of Persons Showers( ) Cafeteria( )
Other Fixtures -y [
D sign Flow(min./required) ,J D gpd Design flow provided c7c/ gpd
Plan Date 8/zfj��77 Number of sheets Revision Date
Title
Size of Septic Tank �/570-41 >°415 Z�:yq Type of S.A.S. q
',Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
e
Date last inspected:
Agreement:
i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 55j4557.1-5.
of the Env'
onmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this B t
Signed Date /�
Application Approved by /Z S, Date `�!f� �y
Application Disapproved by: Date
for the following reasons
Permit No. Q Q — 2 Date Issued �/ 2 40-"-
THE COMMONWEALTH OF MASSACHUSETTS+
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIF ,that the On-site Sewage Disposal System Constructed ( ) Repaired ( t4l Upgraded ( )
Abandoned( )by
i
at A`has been constructed in accordance d
with the provisions of itle 5 and the for Disposal System Construction Permit No. ZOQ� dated
Installer �;y 0-'r V 1„0'T Y f Designer LDO w v C4ge-
#bedrooms -31 Approved design flow 3,JQ gpd
The issuance of this permit shall not be construed as a guarantee that the system will fra)co s designed.�j �Date !IO V/(} Inspector ,/ '1
- . .. t . . . ._..,__
No. —Fee-
_ J THE-COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Xi!5Po,qa16p.5tem Construction Permit
Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( )
System located at !� q �o'a0�S47
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construc 'on ust be completed within three years of the date of this permit'.
Date /� �% Approved by
0-F114E row Town of Barnstable
Public Health Division i S'�PJes P%�
"""""`"BI.E. 200 Main Street a� F
MASS.
1-3
Hyannis,MA 02601 f Ey s
PfYW
0004606238 $ 05.540
7008 1830 0002 0500 8758 JUL 22 2009
_ MAILED FROM ZIP CODE 02601
RETURN RECFIPT
REQUESTfU t�
fit%
C
4
Yardenna . , d
Ifz
69. s Trail �7®t��edct�
r B hle- M arnsta A 02668RETkJRN TO SENDER
i
UNCLAIMED
IJAdADLE TO PoFit,)A D
LSD'': 0280�.+�F00 200 "�D96'�-osi o .�� ��
02+Csas6'b�.34'�r FcUU1
1 rp
ESENDER: COMPLETE THIS SECTION • • ON DELIVERY -
I ■ Complete items 1,2,and 3.Also complete A. Signature i
"`-- I Item 4 if Restricted Delivery is desired. ❑Agent I
I ■ Print your name and address on the reverse X ❑Addressee I
I so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery I
■ Attach this card to the back of the mailpiece,
1 or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
I . ard�►�na �(vrv�fz
-To1
v�esf-- . a�n ✓�I� n(lq
3. S ice Type � I
0 Certified Mail ❑Express Mail
! I ❑Registered ❑Return Receipt for Merchandise
I ❑Insured Mail ❑C.O.D. I
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number - 7008 1830 0002 0500 8758
ransfer from service label)
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540�
Town. of Barnstable Barnstable
Regulatory Services Department I
Ca 1
MAM
sn�tvsrnsiE, U!
ib39�
Public Health Division
Q3 ♦� R
A?��p
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 70081830000205008758
7/16/2009
Yardenna Hurvitz
169 Capes Trail
West Barnstable, MA 02668
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at.169 Capes Trail,West Barnstable MA was last inspected
on July 6,:.:2009:byRobert.Paolini, a certified septic inspector for the State of
Massachusetts.
The,inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged SAS.
• Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER:.. ER.OF HE,.BOAR—_OF:HEALTH
Thomas McKean :R:S:, CHO; :,r c
Agent;af the Board.o.f Health
Town of BarnstableBarnstable
Regulatory Services Department A"maicaCft
MIMSlABT->r. 1 1
9� AKUASM&
Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geller,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 70081830000205008758
8/20/09 V ��
Douglas J. & Sandra Allen
169 Capes Trail
West Barnstable, MA 02668
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 169 Capes Trail, West Barnstable MA was last inspected
on July 6, 2009 by Robert Paolini, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged SAS.
• Static liquid level in the distribution box above outlet invert due to an.overloaded
or.clogged SAS or cesspool
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORPER OF TH BOARD OF HEALTH
�. �
T ` as McKean, S., CH� '
Agent of the Board of Health
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I
°M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be-altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
^�
forms the
computer,
r,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
re"O0 City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
` ❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/6/09
Ins t s tur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable; and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Se ge Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D e
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (Cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a,septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W.Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
`® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1500 gallon septic tank,distribution box and 4 infiltrators.
Number of current residents: unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Well Water
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 7/6/09
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holdingtank resent? Yes No
P ❑ ❑
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is W Barnstable Ma. 02668 7/6/09
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface
p u ace Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1996
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction: `
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 50'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
3'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallon
Sludge depth: 8"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness 5„
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
9"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's.Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Yes
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is Ievel.Box has one outlet lateral.Evidence of solids carryover.Evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4 Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
System is in hydraulic failure.Leaching was full at time of inspection.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
. I
Commonwealth of Massachusetts
Title 5 ,Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
169 Capes Trail
Property Address
Yardenna Hurvitz
Owner Owner's Name
information is W Barnstable Ma. 02668 7/6/09
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two;permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below: I "
❑ hand-sketch in the area below
❑ drawing attached separately
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77 bad
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/V
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t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
169 Capes Trail
Property Address I
Yardenna Hurvitz
Owner Owner's Name
information is
required for W Barnstable Ma. 02668 7/6/09
every page. City/Town State Zip Code Date of Inspection
D. System 'Information (cont.)
Site Exam:
I
® Check Slope
® Surface water
® Check cellar
❑ Shallowwells
Estimated d,lepth to high ground water: Bottom of leachinf 40'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on.record
I
If checked, date of design plan reviewed: 1996
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built
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❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
I
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 annual ranges of groundwater
elevations.
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Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
169 Capes Trail
Property Address I
Yardenna Hurvitz
Owner Owner's Name
information is required for W Barnstable Ma. 02668 7/6/09
every page. City/Town I State Zip Code Date of Inspection
E. Report Completeness Checklist
I
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System,Information—Estimated depth to high groundwater
i
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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t5ins•09/08 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
i
r � jcz TOWN OF BARNSTABLE
LOCATION 3 nW ( SEWAGE#
«LAGS w' XIIfrhSfQble ASSESSOR'S MAP&gLOT���r O®/
INSTALLER'S NAME&PHONE NO. ®� ����`�� �✓ �7�` �✓�19
-SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER ORS �Z�,�'✓/Q AJ
v
<2�ERMITDATE: COMPLIANCE DATE:
�j Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished bye 7'06'7"ti
i - �
�� � ��� +
10 �
�"" !�6
• Dcd8 ' 66, 7. 001
J-
NO. --�iL(�� VEE"'
THE COMMONWEALTH OF MASSACHUSETTS
fl 7 RARNSTfiCP�L MASSACHUSETTS
�Nyyfirafivn for �tS II$�tC 5g$#enT �IIttS#x>LtrttIIrt exxrtt#
Application is hereby made for a Permit to Construct(X or Repair( )an On-site Sewage Disposal System at:
Locat' n Add re s or Lot No. Owner's Name,Address and Tel.No.
�loT 3 # 1(,, CNANkPiotJ t_l pCQ S l t�C_'
vvEST G.a2N STA-GNJ6) 'vA -2 b 41� 5 C �j '_Xj 15s
P+E�nf3cL.o�.� , nM o 2.3 S 9
G Boo
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
(,0(LTo1_0)VA _0K'C'ILvtTtDnl Ov./ti cAPt Er.�tUtt�lEti2tt"Zl i t N C
1bS wAKE&"j B�MhoZ(ogg �3Q N�A�ru ST2��G1 yA2 A00r") `"q
LhAtLSTo�S MILLS, PM sb _-1-1 1- g3Qq So 3( 2 h- Q-O
Type of Building:
Dwelling No. of Bedrooms 1'1 Garbage Grinder QVb)
Other Type of Building No. per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 43 3 0 gallons per day. Calculated daily flow 33 4 .q gallons.
Plan Date iyOV. 20, Aq! Number of s��eets 1 Revision Date N.O�
Title SITE tav�Jr� S£wA(ar` PLA tJ of (lAT `51 ltoq C ra4�S TQ A 1L W (S,�(LN MA
Description of Soil Ckj'F_AW MIY T)iVM 54��,Nf) w) 69U,S of SZLTL1 SA'-J0 AWQ STa,nl,
go W/'\T L_ CVr0JKntF_-c_cS
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has bee iss Zoard o lth.
Signed Date
Application Approved by Date
Application Disapproved for;the following reasons
Permit No. T Date Issued
No. FEE
THE COMMdNWEALTH OF MASSACHUSETTS
Y �t7 SAQN 5TARAX —, MASSACHUSETTS
&kppliratton for Cons#rnrtton jJerntit
Application is hereby made for a Permit to Construct or Repair( ) an On-site Sewage Disposal System at:
Locati n Addres or Lot No. Owner's Name,Address and Tel.No.
�LoT 3 V I(o9 CAPES TQAI� CNAMp1ON (i��WC2S, 1►�G
w�S� c3.a2Ns�At3��� A 300 ooX St�E�� �L�Tt tss
G 3800
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
(LTuLcsTN c oti1;eLV rrldnl , ;r,,c
�o�� CAnC CNiC,I �2i��1
-It's "A, o) A9) '�� At r., STf-�. _1 YA(ZmoL)— , q
6hg2STUNS M��I.S� yY`A 5b _-7�1 4 ' q�iQ'! 150% 4'�4- 1
Type of Building:
Dwelling No. of Bedrooms TId2EC Garbage Grinder 01b)
Other Type of Building No. per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow '�3 U gallons per day. Calculated daily flow 3 4 •q ,.gallons.
Plan Date KOV 1Z, 1Ga5 Number of s ets 1 Revision Date N041X�-
Title SITE R" S-wAGk PLAN of ((c)T S) 41(oq C„orSTQA)L� w�ST &,QNcTw;tc MA
Description of Soil C',efaN MEmv(y\ SAwf) w1 P R o 61- SILTLi cA)\Ja AND Sfi6nrc
Ko yjATF.11- CtvcpvNca`(LC�
G1LUVtJ0wP�\-C-I(- CL Et-. - 4-0
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
~'-"Certificate of Compliance has bee issu by-thi oard of alth. 12,Signed Date � 7
Application Approved by 4kDate
Application Disapproved for the following reasons..,
Permit No. h ' Date Issued
e+
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
(gPr#tftxttte of 10.10myltttnce "
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired/replaced ( ) on
by for
at le 6213 - / h s been constructed in
accordance with the provisions of Title 5 and five for Disposal System Construction Permit No. — .1dated
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
+1:R-�-..rfs�'"1•, - _ _�."+w"..-^`-.�...,.,®... _.>Ali.au':urs.,..tawa+..rxfi...a,..e.........^,.....,,w-.._ _ _ ,.. .._.^x:`.as. -- ---..-�
THE COMMONWEALTH OF MASSACHUSETTS
No. �` 7 , MASSACHUSETTS FEE /a 4,
Pispoent �5gstem VA-lons#rurtton jJErmt#
Permission is hereby granted to _ e
to construct ( ) or repair( ) an On-site Sewage System located at 44
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction.must be completed within three years of the date below.
DATE .ice *`I Approved
FORM 1255 Rev.3/95 A.M.SULKIN CO.-BOSTON,MA
ENVIRO�CH LABORA170R.�]S, INC.
MA Cert. No.: M-MA 063
449 Rte. 130 • Sandwich, MA 02563
'(508)888-6460 • 1-800-339-6460
FAX(508)888-6446
t
i
3
CLIENT: Champion Builders LOCATION: Lot 3
t` Caper Trail
W. Barnstable, M
SAi,IPLE DATE: 1-2-96
COLLECTED BY: L. Wi1F & Son Wells DATE RECEIVED: 1-2-96
TIME: 9:30AT.. LAB I.D. #: E1002
JOB TYPE: New well SAMPLE I.D. #: E1002
WELL SPECS.,: 1751/130, static
4" PVC well
Flow: 10 G.P.M.
v
RESULTS OF ANALYSIS:
Parameters Units Recommended Result
Limit
Coliform bacteria/100ml = (MF Method) 0 i 0
pH ' pH units 6.0-8.5 6.54
Conductance um 500 62
Sodium '' mg/L 28.0 7.9
Nitrate-N mg/L 10.0 0.12
Iron m /L 0.3 0.45
Manganese t 'mg/L 0.05 0.025
Hardness mg/L as CaCO3 50y 16.9
Sulfate i mq/L 250 10.2
Potassium mg/L 20.0 1.2
Alkalinity fir` mg/L 200 21.0
Chloride mg/L 256 9.0
Turbidity i r�TU 5.^ 22.0
Color ' APC units 15.:0 LT 1.0
Volatile Organics See enclosed report.
EPA 524 ` ug/L None detected.
F'
� f
COMMENT: Iron level is not a health hazard.
Yes No WATER IS SUra'ABLE FOR DRINKING PURPJ S FOR PA TERS TESTED.
,4 xxx .
Date z �
Ro ald J. Sa i
LT = Less Than La^oratory rector
I
Ofh'. LAPUCK LABORATORIES PHONE NO. 617 923 0301 Jan. 23 1996-03:19AM P2
LAPUCK
LABORA.TORIM, INC. ENVIRONMENTAL 'f FSTING
WAST13 WATER DISCHARGE.
50 Hunt Street " TESTING
Watertown MA 02172
(617) 923-03W° FOOD ANALYSIS.
CHEMICAL ANALYSIS
lax (617) 92370301. FORI?NSIC_TI3STING
REPORT
LAB NO. 54181 January 18, 1996
Mr.Ron Shari
ENVIROTECH LABORATORIES,INC. Sample Received: 01/05/96
449 Route 130 Client I.D.: Champion_
Sandwich, MA 02563 Sample I.D:: E1002
Test Results:
yolatile Organics pnU(ug/L')
l' Method H524
Benzene N.U, 1,2-Dichloropeop8ne N.D.
Bromobewene 48N.D. 1,3-Dichloropropane N.D.
Bromochloromethane N.D. 2,2-Diehloropropane N.U.
Bromodichllrromothane �'N.-D. 1,1-Dlchloropropenc N,D.
Bromoform 'IN.D. Cis-1,3-Dichloropropcne N.D.
Bromomethano "N.D. 'Trans-1,3-Dichloroproperle N.D.
N-Butyl Benzene N.D. Ethylbenzene N.D.
Sec-Butyl Benzene I N.D. iiexachlorobutadicne N.D.
Tert-Butyl Benzene s N.D. Jsopropylbenzene N.D.
Carbon Tetrachloride N.D; P-lsopropyltoluene N.D.
Chlorobenzene IN.D, Methyl Chloride N.D.
Chloroethane .N.D. Naphthalene N.D.
Chloroform N.D. N-Propylberimne N.U.
Chloromothane i N.D. Styrene N.U,
2-Chlorotoluene N.D. 1,1,1,2-Tetrarhloroethane N.D.
4-Chlorotoluene 'N.D. 1,1,2,2-1'etrachloroethanc N.U.
1,2-Dibromo-3-Chloropropane N.U. Tetrachlorocthene N.D.
Dibromomuthane ! N.D. Toluene ' N.D.
1,2-Dichlorobenzenc N U, 1,2,34richlorobeazene N.D.
1,3-Dichlorobenzcne N.D. 1,2,4-Triclilorobenzene N.D.
1,4-Dichlorobenzene 'N.U. I,1,1-Trichloroethane N.D.
Dibromochloromethane. N.D. 1,1,2-1'richlorocthane N.T .
1,2-Dibromoethane (EDB) a'N.D. Trichlorofluonnmethane N.D.
Dichlorodifluoromethane N.D. TrichloroethiLne N.D.
} 1,1-Dichloroethane , N.D. 1,2,3-Trichloropropane N.U.
1,2-Uichloroethtmc(EDC) N.D. 1,2,4-Trimethylbcnzene N.D.
LI-Diehloroethelcne N.D. 1,3,5-77imethylbcnzene N.D.
Cis-1,2-Dichloroethylene N.D. Vinyl Chloride N.D.
Trans-l.2-Dichloroethylene :•N.D, 1'ofalXvlene! N.D
N.D. =Not'botected Analysis Date;: 1/5/96
Method Dewedon Limit =0.5 u 1,
Rg�verjes of b ernal,Stan r s and Sun ► ate— -
Fluorobenzenc !; , 92 1,2-Dichlorobenzene-M 92
P-Bromofluorobenzene 95
D JP. -MA 061 1 1
!1 es�l C a I a. . . onsultln S rVl �,,s� es 1'ohten msa, .ab M na elf
�' a cesti,. P
far o;vcr 30 Years
71�iq,ruiwtt c:icndcre cl ulxm the condtUcx..lhai t la not to be rc.t,,,hiced.wholly Y or inpart for M4yc1lAn4 N�other purpnsts rwtr out
ASSESSORS MAP ftj:`' _W7
No. `� .� / f PARCEL NO._ �7 . ®�/ Fee--'- -------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application Ar Well Con0ructionpermit
/(f ciev wor �t
ic lion ismade to Construct ( ), Al er ( ), or Repair ( )an individual Well at:
Location — Address Assessors Map anJ Parcel
---------- �12 -- -- — 6_ ---- --------------
`'O�wn'r - Address
-5 ------------------------_
--------------------- -------------------------------------------------------------------------------------------------
Installer — Driller Address
Type of Building
Dwelling---------------------------------------------------------------
Other - Type of Building ------- No. of Persons------------------------------____________
Type of Well-- t C
Purpose of Well----IV0_�O�---------------- ---------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until Certificate .of Compliance has been issued by the Board of Health.
Signed rAa� — K/. CY----- - - - ---- ---- --
date
Application Approved By -- _ - -- — -��� _fi__
- date
Application Disapproved for the following reasons:-----------------—--------------_____-_--------__—__�__--________
------------ -- --- - ----_--_
----------
date
�,�
PermitNo.--�'�--e— -------------- Issued---------------------------------��---------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate ®f (Compliance
THIS IS TO CERTIFY, T t the Individual Well Constructed-E.-), Altered ( ), or Repaired ( )
c
bY-------- - -�=- - -------- --- -- ---------------------------------------------------------------
— Installer— —
has been installed in accordance with the provisions of the Town of Barnstable Board of Heeaallt�-th Private Well Protection
Regulation as described in the application for Well Construction Permit Noa'e - .;?.2'�Wilted erz�___ � 01-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE- --- —-— -- — - --- -- Inspector------------------------------------- — - - ---
,• __,� _ a.�r�F.�,.p: ., f� ` r�ty �per- �,_�y_ � ;,;,,y.t �x��,'t .
-v.•�.r...�''.t,,..-.•.�.��,�y'>/t�7i�-�`.,,� lY*r�'�,yr+lytry.,{'�i'. �•.�Y"'r'y'�y,� .�.tc "'�';'tar'f"�In^t4�✓`..'"S>n7'Y�"'�. `��' f`�Vrk.7`1'^S�1tl!""'�O�/7^.-.+r Rl�'�+'s ls'>�F+t :-7t'i�'�i�t.,..
' �-------------- fv 0/ Fee-----
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application-*rVell Congtruct ion Permit
Ap lic do"is h v mad it to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
��-�- , ---------- p-A4- -- -_ _ I --- '-- - - r P -
Location — Address �w Assessors Ma and PamI
------ - - - ------ _ ------- --------
Owner _ Address
- -! - ------------------ --- --------------------------------
Installer Driller Address
Type of Building
Dwelling
` Other - Type of Building ------- No. of Persons--------------------------------------_________
I' ----- Capacity Type of Well- � C - -- a --- - - -- w - - - -:- - -= --- -
` Purpose of Well Q �--------------------------
i
Agreement:
r The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until Certificate .of Coomplli''ance//has been issued by the Board of Health.
Signed r ---------- ----- —=----- --
date �y
Application Approved By
date
Application Disapproved for the following reasons:-----,----------_i-------------------------------------_—__________
,. ------------------------- ----—-- —- - ----------------
sate
Permit No. -� � "Ooo;�" - Issued---- -- - --c— --------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, TbLat the Individual Well Constructed-), Altered ( ), or Repaired ( )
bY--------.)------ -4------ ---------- ----------- -------------------------- ---------------------------------------------- - ------
Installer
pAd,
at ' = � ' -- -- -- - - - =-- -------------------- -
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private.Well Protection
Regulation as described in the application for Well Construction Permit.No40-'-�y ;2!- ted
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-- - =-- — - -- - -— - Inspector-------------------------------------------------------------------------
( BOARD OF HEALTH
TOWN OF BARNSTABLE
Vell Cone;truct ion Permit
' No. - `-'- - w / / Fee-__� _4—-------
/ Cif/
Permission is hereby granted �_� � ----------------------------------------------------------------
to Construct (�-), Alter ( ), or Repair ( ) an.Individual Well at
No. --— --- --------------------------------------------------------------------
- -------------
Street
as show�n�on the anplicati-w for a Well Construction Permit -r
No. - - - - - - - Dated-'-/ - - - -------------------=
Board of. Health
DATE--- -� - — - - -- ----— -
r,
Department.of Environmental-Management/Division of Water Resources .
WELL COMPLETION REPORT
0.
WELL LgQU_rTfeN C� 2 ���J� GEOGRAPHIC,DESCRIPTION
Address // *30
S E .W of
IT bt)
'C.Ity/Town #77 'l /. lie
-. 7t'C. . .(road)
Well owner
Address " N S E W of
(mL in tenths)
Board of Health permit obtained`. yes ❑ no,❑ urreasect. w/ (road)
WELL USE WELL DATA ✓ 7
Domestic. Public❑ Industrial ❑ Total well depth ft.
Monitoring Elthi r Depth to bedrock-�d/ ft•
p Water-bearing rock/tinc ogs olidated material:
Method drille
Description n
Date drilled
Water-bearing
CAST f; /�ItD r 1
-Y 1) From To
Type f•;
Length JIf I ft.'Dia(l, .} 'in.71 2) From To
31.From— —To
Length into'bedrock It �V(�
Gravel pack well dia.
Protective well seal: ♦ 1 a
Screen,: rW4.1F Iry
tr
Grotit-❑ Other Slot$, length_ from_to W
a
STATIC WATER LEVEL(all wells)
3d
Static water level below land surface , ft. Date
A
WELL TESTi production wells)
Drawdown after pumping hr., � ml at gpm
How measured' Recovery. (t. .'after_hr. 'min,
LjofF01MATIONS COMMENTS
Qll, 744, Driller. 1p4 Fry
Firm
AddressIt
' Q
n City/Town
r
Supervising Driller Reg.#
�'S'narvre of supervising registered well driller,
ileese print firmly
., A:. ,,: ;r:• 4YrrB0AA ()F,H.HEALTH,d PY,,
t ]
ENVIROTECH LABORATORIES, INC.
IVA Cert. No.: M-MA 063
449 Rte. 130 . Sandwich,MA 02563
(508)888-6460 • 1-800-339-6460
FAX(508)888-6446
CLIENT: Champion Builders LOCATION: Lot 3
Caper Trail
W. Barnstable, M
SAMPLE DATE:. 1-2-96
COLLECTED BY: L. Wile & Son Wells DATE RECEIVED: 1-2-96
TIME: 9:30AM LAB. I.D. #: E1002
JOB TYPE: New well. SAMPLE I.D. #: E1002
WELL SPECS. : 1751/130, static
41, PVC well
Flow: 10 G.P.M.
RESULTS OF ANALYSIS:
Parameters Units Recommended Result
Limit
Coliform bacteria/100m1 (MF Method) 0 0
pH pH units 6.0-8.5 6.54
Conductance umhos/cm 500 62
Sodium mg/L 28.0 7.9
Nitrate-N mg/L 10.0 0.12
Iron mg/L 0.3 0.45
Manganese mg/L 0.05 0.025
Hardness mg/L as CaCO3 500 16.9
Sulfate mg/L 250 10.2
Potassium mg/L 20.0 1.2
Alkalinity mg/L 200 21.0
Chloride mg/L 250 9.0
Turbidity NTU 5.0 22.0
Color APC units 15.0 IT 1.0
Volatile Organics See enclosed report.
EPA 524 ug/L None detected.
COMMENT: Iron level is not a health hazard.
Yes No WATER IS SUITABLE FOR DRINKING PURPO S FOR PA TERS TESTED.
X}IX
Date Z �
Ro ald J. Sa i
IT = Less. Than Laboratory rector
FROM LAPUCK LABORATOR I ES — PHONE NO." : '.617: 923 ,0301 ' Jari 23 1996-03.`19AM P2
�7.
L
AP
LABORATORIES, INC. ENVIRONMENTAL TESTING
WASTE WATER DISCHARGE
50 Hunt Street TESTING
Watertown, MA 02172 FOOD ANALYSIS.,
(617) 923.0300 CHEMICAL ANALYSIS
Fax (617) 92.3-0301. FORENSIC-TFSTING
ItEP012T: January 18, 1996
LAB NO. 54181
Mr.Ron St3an rued: 01/05/96` J.
ENVIROTI✓CH LABORATORIES,INC. Sample Rece'
1 . client 1 n champion
449 Route 30
Sandwtah; MA 02563
Sam le I D• `B1002 ,
Test P-caultsi
Volatile Organics-01)(119/1-)
Method H524
N.D, 1,2-Dichloropropane N.D.
Benzene N.D.
Bromobenzene_ N.D. 1,3-Dichloropropane
>}mmochlommethane N.D. 2,2-Uiehlaropropane N.U.
Bromodichloromcthane N.D. 1,1-Dichloropropene N.D•
BromofOrin N.U. Cis-1,3-Dichloropropcne N D.
N.h• 'flans-1,3-Dichloropropene N.D.
iiromomcthane
Cthylbenzene N.D.
N-Butyl Benzene N.l): •
Seo-Butyl Benzene N.D. I�exachlorobutadicne . N.D.
N.D
Ten-Butyl Bonzenc N.D. Isopropylbenzene •
Carbon Tetrachloride N.D. P-lsopropyltoluene N.D.
Chlorobenzene N.D. Methyl Chloride N.D.
ChloroethI6ne N.U. Naphthalene N.D.
Chloroform N.D. N-Propylbenzene N.D.
Chloromothane N.D. Styrene N.D.
2-Chlorotoluelte N.D. 1,1,1,vretrachloroethane N.U.
4-Chlorotoluene N.U. 1,1,2;2-•1'etrachtorocthanc N.D.
1,2-Dibromo-3-Chloropropane N.U. Tetrachlomcthene N.D.
Dibromomuthane N.U. Toluene N.D.
1,2-Dichlorobenzenc N.U. 1,2,3=Crichlorobcnzene N.n.
%3=Dichlorobenzene N.D. i;2,4-Trichlorobenzene N.D.
1,4-Diclilorobenzene N.D. 1,1,1-Tricbloroethane Np.
Dibromochloromethane N.D. 1,1,2=1'richloiacthane N n
1,2-DibioThoethane (EUB) N.D. 1,rjchlorc�fiuommethane N D ;
Dichlorodifluoromethane N.D. Trichloroethane
1,1-Dichloroethane N.U. 1,2,3-Trichloropropane �•D�
1,2-Dichlorocdwo(EDC) N.D. 1,2,4-Trimcthylbcnzene ND
1,l-Dichloroethelcne N.D. 1,3,54'rimethylbenzenc N D
Cis-1,2-Dichloroethylene N.D. VinytChloride N.D
Trans-l.2-Dichlameth ene N•Dl, '1'0�1 Xylene N.D,:--
N.D. =Not.Dotectecl Analysis Date: 1/5/96
Method Detection Limit =0.5 ug/11
Rgsover'►es oS.lnternal.fitHn r is tend Surgate%
F16orobonzenc 92 1,2-Dichlorobenzene-d4 92
P-Bromofluorobenrene 95 \
T'QSJf1l2g'R COnsult�l7� Services es Fontenarosa,Lab.Manager
,,-3 -,
71nc..mlxut Is_rcndcmJ u�+nu the conduon.lhn�h le not,'t toej kwv,&t,wholly o,!n pact fir nclv�nlwin�t or,oilpr purpns�s ova