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HomeMy WebLinkAbout0114 MAIN ST./RTE 6A(W.BARN.) - Health 114Main Street Y ~ 'vilest Barnstable A�= 11'1 '='001 0 E� (q7® 7 lr t✓� � n L � MA o j u uoc� 11 4Main Street t West Barnstable A'= ll l - 001 0 9 i i �I �I k I 9 A 9 i y 1 y� 3 G f I IN ® s UPC 12043 No.53LBE t�lA.STL�9G�00.D! „ j e 6 P�fs♦WUf �' r, . Yo IVIO 1&)1-� pY a 11 c. 41, C3= Y 60 v< VeN t r • ,xS 4� q � -� � }� y T s' t� a�?,' �y+ `,a `•�g,. Mr. ..e' d J 'aS.a ��„ a t �V . F R l - r��` ry �"♦ ,,N _ , `}#3�q.:Y W W�'iy � :5,”.:GAF` .. �l W � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,•'•- 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information is every West Barnstable required for eve MA 02668 3-16-15 page. Cityrrown 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 forms A. General Information on the computer, I use only the tab 1. Inspector: key to move your cursor-do not Darrell Stone use the,return key. Name of Inspector ��e� Cape Cod Septic Inspection �V Company Name P.O. Box 1466 Company Address Harwich MA 02645 Cityrrown State Zip Code 508-240-2500 S14995 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: ® P ses /jE1 Conditionally Passes ❑ Fails ❑ ds urthe valu o y cal Approving Authority 3-17-15 Inspector's Sign t e 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. System•Page 1 of 17 t5ins.3113 Title 5 Official In e n Fonn:Subsurface Sewa a Disposal Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information is required for every West Barnstable MA 02668 3-16-15 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 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 114 RTE 6A West Barnstable Property Address William and Robi-i Kirby Owner OWnet's Name information isequired or every West Barnstable MA 02668 3-16-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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)(1b)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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM ,. 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information is required for every West Barnstable MA 02668 3-16-15 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 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 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 day flow t5ins-3/13 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 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information is required or very West Barnstable MA 02668 3-16-15 f e page_ Cityrrown 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"non 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•3113 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 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owners Name information is required for every West Barnstable MA 02668 3-16-15 page. Citylrown 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): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example_ 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name required for is every West Barnstable required for eve MA 02668 3-16-15 page. Citylrown State Zip Code Date of Inspection D. System Information Description: 3 Bedroom residential dwelling Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Private well Detail Sump pump? ❑ Yes ® No Last date of occupancy: Current 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 holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for 9 p y Voluntary Assessments 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information is West Barnstable MA 02668 required for every 3-16-15 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: Unknown 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 1/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 114 RTE 6A Wes-Barnstable Property Address William and Robin Kirby Owner Owner's Name information is required for every West Barnstable MA 02668 3-16-15 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: 1988 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth belowgrade: 11 +� feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Apparnet good condition Septic Tank(locate on site plan): Depth below grade: 5 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: 1000 gallon Sludge depth: 16" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5a''r 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information is required for every West Barnstable MA 02668 3-16-15 page. Cityrrown 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 16" Scum thickness 12" 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 5" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Normal liquid level No sign of leakage Concrete outlet tee OK The septic tank is due for pumping Recommended maintenance pumping eve 2-3 years 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° M 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information is required for every West Barnstable MA 02668 3-16-15 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Comments(a-i 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5e'p 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information is required for every West Barnstable MA 02668 3-16-15 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 2.5' 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.): Grade to box 21" OK condition 1 Outlet Heavy scum removed Water level high due to outlet pipe not being level 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.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information isequired or every West Barnstable MA 02668 3-16-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): 4 (4x8x1')chambers with stone Grade to chamber 78" Cover 21" Bottom 94" Ponding 2" No sign of hydraulic failure 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 gr oundwater inflow g ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information is required for every West Barnstable MA 02668 3-16-15 page. Cityrrown 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•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts U'111 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information is required for every West Barnstable MA 02668 3-16-15 page. Cityrrown 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: ® hand-sketch in the area below ❑ drawing attached separately E1 B a�t �A 5�011171 wd C 2 2o--Z 7--2 I ' 3 23-d sZ-lo 3 L t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M s 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner Owner's Name information isequired or every very West Barnstable MA 02668 3-16-15 page. City/To in State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Elevations shot during the inspection Top of foundation ELV. 50.0 Benchmark Bottom of Chamber ELV. 39.34 Property slope to ELV. 34.92 NWE 3-16-2015 Separation >4' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspectio n Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 114 RTE 6A West Barnstable Property Address William and Robin Kirby Owner information is Owner's Name required for every West Barnstable MA 02668 3-16-15 page. Cltyrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® 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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file !Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 William E Kirby&Robin S.Kirby 307 Radnor StreetUl � NashvJUe,TN 37211 � pm. Mr.Thomas McKean Town of Barnstable Health iDept. 200 Main Stet Hyannis,MA 02601 February 10,2015 ]Dear Mr.McKean, I am wring to you,as per our conversation,to put on regard that the property at 1-14 Main Stet,West Barnstable,MA was originally built as a 3 bedroom 2 bath home and has a 3 bedroom septic. The property was owned,designed and built by my father in law,Uoyd Sherwood. As I understand from hire,in the easy 197(°s 19Ws he had decided to maize the two small bedrooms on the left side of the house,into one large bedroom for my wife Robin. Since they were not going to have any other children,this would give her a larger room. I do not know the exact configuration of the walls since the home was built before nay birth,and my marriage to Robin,however,looking at the room now you can see there are 2 closets on opposite sides of the room giving each bedroom a closet. My father in law had always intended to build back on the third bedroom off the main level. In the early 1997Vs, being an Architect,he drew up the plans to do east that. Sadly,due to the passing of his wife Elizabeth in1994, after a long illness,he then had to change has plans. We bought the house from ham in 2005. Thank you for all your help in this matter. If there is anything else you need,please do not hesitate to contact me. Sincerely, Y 11im F.Wirby I lVo 70 Ct (ems ,�Grnd l� M/,L Page: 1 of 1 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) Report Prepared For: Report Dated: 9/4/2014 Sally Desmond Desmond Well Drilling Order No.: G1483222 P 0 Box 2783 Orleans, MA 02653 Laboratory ID#: 1483222-01 Descripti Water-Drinking Water - I Sample#: ,Sample Loc n: 114 Main St.W. Barnstable,MA Collected: 09i02/2014 Collected by: Customer Received: 09/02/2014 Routine M ITEM RESULT UNITS RL MCL METHOD# TESTED Nitrate as Nitrogen 3.3 mg/L 0.10 10 EPA 300.0 9/3/2014 r Iron ND mg/L 0.12 0.3 SM 3111 B 9/3/2014 Manganese 0.0032 mg/L 0.0030 SM 3111 B 9/3/2014 j f j 6.1 PH AT 25C NA 6.5-8.5 SM 4500-H-B 9/3/2014 p Sodium 15 mg/L 2.5 20 SM 3111 B 9/3/2014 Total Coliform Absent wA o o SM 9223 9/2/2014 Conductance 150 umohs/cm 2.0 SM 2510E 9/3/2014 Water sample meets the recommended limits for drinking water of all the above tested parameters. i Attached please find the laboratory certified parameter list. Approved By: (Lab Director) a J I ND=None Detected' RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 i CERTIFICATE OF ANALYSIS 3 ` �M Barnstable County Health Laboratory `M-MA009) Recipient: Sally Desmond Matrix: Water-Drinking Water Desmond Well Drilling Sampled: 09/02/2014 14:00 P 0 Box 2783 Received: 09/02/2014 14:35 Orleans, MA 02653 Collection Address: 114 Main St.W. Barnstable,MA Sample Location: Order#: G1483249 Description: 3day-114 Main St voc only Lab ID: 1483249-01 Date Analyzed: 9/5/2014 @ 16:08 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Water sample meets the recommended limits for drinking water of all the above tested parameters. I --- --- EPA 524.2 - Volatile OrganiCS Eby GCIMS j Result MCLM1 Result MCL MDL i Parameter I ug/L ug/L ug/L Parameter ug/L ug/L ug/1_ Dichlorodifluoromethane ND 0.50 lChloroform --- i 1.3 ! 80 0.50 Chloromethane �_ ND _ _ 0•50 icis-1,2-Dichloroethene - ND 70 0.50 -- �Vinyl chloride - ND _ I 2 0 i _0.5o cis-I.,3 Dichloropropene _ ( -ND _ T -_r Bromomethane ND t 0.50 Dibromochloromethane ; ND 0.50 11,1,1,2-Tetrachloroethane 0.5! 0 11Dibromomethane - - - ND- o.so -._. 0 --- ----- 0 1,1,1-Thchloroethane ND 200 ` 0.50 iEthyl benzene 1 ND 700 0.501,1,2,2-Tetrachloroethane _ f ND 0.50 !iHexachlorobutadiene _ ND i -- i 0.50 5.0 0.5o Iso r0 (benzene ND 1,1,2-T_richloroethane ND , i i; p py 0.50 �1s.o r--- 1,1-Dichloroethane ND i 0.50 '(Methylene chloride ND .So 1,1-Dichloroethene - - ND 1-7.0 i 0.50 i!Methyi-tert-butyl ether- -- _ �0.58 - 0.50 j1,1-Dichloropropene ND 0.50 ;,Naphthalene ND -^ 0 50 -- 11,2,3-Trichlorobenzene i ND -_ 0.50 -iin-Butyibenzene .ND. _. ±_ _0.50 11,2,3-Trichloropropane ; ND l 0.50 In-Propylbenzene j ND 0..io 11,2,4-Thchlorobenzene j ND f 70 0.50 (ip-Iso_propyltolu_ene ND 0.50 i1,2,4-Thmethylbenzene i ND ; -0.50 _ sec-Butylbenzene ; ND - 0.50 11,2-Dibromo-3-chloropropane j ND 0.50 ;!Styrene _-I - ND_ s 100 0.50 I +--0.50 � tert-Bu (benzene _ _ ND - o_so !1 2-Dibromoethane(EDB) ND ty _ 112-Dichlorobenzene i ND 600 0.50 jTetrachloroethene ND 5.0 0.50 R�11,2 Dichloroethane I 5.0 0.so Toluene _--._. --- - ND - `--1000�- o5ti -`- _- ND ^-- _. _ _--- '1,2-Dichloropropane ND 0.50 Total xylenes ; ND :10000 0.50 1,3,5-Trimethylbenzene j ND ; 0.50 trans-1,2-Dichloroethene - ND 1100 0.50 1,3-Dichlorobenzene I ND ! p p - T - 0.50 trans-1,3 Dichloro ro ene ND 0.50 1,3-Dichloropropane I ND 0.50 i Trichloroethene ; ND 5.0 0.50 1,4-Dichlorobenzene ND 1 5.0 1- -0_50- jlTrichlorofluoromethane I ND 0.50 ND 2,2-Dlchloro ro ane 0.5o p p i r t ! Surrogates %Recovered QC Limits(V 2-Chlorotoluene I ND 0.50 1 ip-BrornOftorobenzene 900/o i 70 130 4 Chlorotoluene j ND I i 0.50 -i 1,2-Dichlorobenzene-d4 90% ` 70 130 �Benzene _ ND 5.0 # 0.50 - - -- --_--.__ Bromobenzene -- - - ND -�l 0.50 -{ (Bromochloromethane ND }� j 0.50 t Bromodichloromethane _ - ND- ! _ - --�T 0.50 iBromoform ; ND i 0.50 Carbon tetrachloride ND 5.0 1 0.50 Chlorohenzene _ _ ; ND ioo I 0.50 i IChloroethane ---� - -- i ND ; 0.50 Approved By: ,. 'C :''..>, Attached please find the laboratory certified parameter list. ; �- (Lab Director) NO=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1.of 1 r Massachusetts Department of Environmental Protection Bureau of Resource Protection Well Completion Reports Well Driller Please specify work performed: Address at well location: New Well Street Number: Street Name: 114 MAIN STREET Please specify well type: Building Lot#: Assessor's Map M [Domestic —1 A111 Assessor's Lot#: ZIP Code: Number Of Wells: 001 02668 City/town: Well Location BARNSTABLE In public right-of-way: GPS r Yes G No North: West: 41.72444 70.39398 Subdivision/Property/Description: Mailing Address: click here if same as well location addres Property Owner: Street Number: Street Name: WILLIAM KIRBY 114 MAIN STREET City/Town: State: Engineering Firm: BARNSTABLE MASSACHUSETTS ZIP Code: 02668 Board of health permit obtained: ref Yes !; Not Required Permit Number: Date Issued: W2014 024 8/8/2014 --- Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) 44� Well Driller - General Well Form DRILLING METHOD Overburden Bedrock Auger ( C--Choose Bedrock-- " WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop in drill Extra fast or slow Loss or addition of (ft) stem drill rate fluid 0 20 IFine To Coarse jBrown YES r NO 0 Fast G Slow fit Loss G Addition 20 23 iFine To Coarse lBrown rd YES r NO i r Fast ro Slow 0 Loss ro Addition 23 35 IClay Light Gray r YES (O GO Fast Get Slow r Loss tO Addition 35 40 Sift Brown YES G NO G Fast r Slow t Loss Addition 40 50 Fine To Coarse Sand 113rown r YES r NO G Fast G Slow r Loss r Addition WELL LOG BEDROCK LITHOLOGY Visible Extra From Drop in drill Extra fast or slow Loss or addition of To(ft) Code Comment Rust Large (ft) stem drill rate fluid Staining Chips Choose Code C YES 0 NO 0 Fast r Slow Loss r Addition r Ye Ye ADDITIONAL WELL INFORMATION --..._.-._..---------- Developed Yes r No Disinfected (t,Yes Total Well Depth 50 Depth to Bedrock Fracture .............................................................. Surface Seal Type one Enhancement ( Yes t , No CASING I(?I Is Casing above ground From: 1 To: 0 From To Type Thickness Diameter Driveshoe 0 47 IPolyvinyl Chloride Schedule 40 4 FJ Ye SCREEN r No Scree From To Type Slot Size Diameter 47 50 IStainless Steel Well Point 0.012 4 WATER-BEARING ZONES ( 1 DRY wEL From To Yield (gpm) 9 50 12 PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed Pump Description Horsepower Submersible 1/ e Massachusetts Department of Environmental Protection 7, Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Pump Intake Depth(ft) 45 Nominal Pump Capacity(gpm) 10 ANNULAR SEAL/FILTER PACK From To Material 1 Weight Material 2 Weight WaterBatches Method Of Placement (gal) Choose Material lChoose Material --Choose One WELL TEST DATA Time Pumping Time To Recovery (ft Date Method , Yield(gpm) Pumped Level (ft Recover BGS) (HH:MM) BGS) (HH:MM) B/11/2014 Constant Rate Pump 12 1:30 11 0:01 9 WATER LEVEL Date Measured Static Depth BGS (ft) Flowing Rate(gpm) 9/11/2014 9 12 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. THOMAS E Supervising Driller DESMON Monitoring[M] III, Driller DESMOND III Registration# 764 Signature THOMAS, DESMOND WELL Date Job Complete Firm DRILLING INC. Rig Permit# 023 9/11/2014 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out Owner ` Tenant Address -7 1 a 1 Address OT Complia a Remarks or Regulation # I NO Recommendations 2. Kitchen Facilities -�� ew.. _ 3. Bathroom Facilities -'ice= -Q 4. Water Supply ; 'r 5. Hot Water Facilities 6. Heating Facilities As 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 3 6 L 8 9— N7, 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector ` If Public Building such as Store or Hotel/Motel specify here CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory (M-MA009) 9'S'�C41C,hni Report Prepared For: Report Dated`: 5/5/2011 Bernie Klotz BK Real Estate, Inc Order No.: G1161802 1645 Route 28 Centerville, MA 02632 Laboratory ID#: 1161802-01 Description: Water- Drinking Water Sample#: Sample Location.=1-14`Main-St,=W Ba"instable,=MA'S Collected 5/3/2011 Collected by: Customer Received 5/3/2011 t Routine ITEM RESULT UNITS RL MCL METHOD# TESTED Nitrate as Nitrogen 4.0 mg/L 0.10 10 EPA 300.0 5/3/2011 Copper 0.16 mg/L 0.10 1.3 SM 3111 B 5/4/2011 Iron ND mg/L 0.10 0.3 SM 3111E 5/4/2011 pH 6.3 PH AT 25C NA 6.5-8.5 SM 4500-H-B 5/3/2011 Sodium 17 mg/L 1.0 20 SM 3111E 5/4/2011 Total Coliform Absent P/A 0 0 SM9223 5/3/2011 Conductance 180 umohs/cm 2.0 EPA 120.1 5/3/2011 Water sample meets the recommended limits for drinking water of all the above tested parameters. Attached please find the laboratory certified parameter list. Approved By J(Labirector) i rti3 r� M tV r 1 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House,-Po. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS ,o Barnstable County Health Laboratory (M-MA009) Recipient: Bernie Klotz Matrix: Water-Drinking Water BK Real Estate, Inc Sampled: 05/03/2011 13:41 1645 Route 28 Received: 05/03/2011 14:28 Centerville, MA 02632 Collection Address: 114 Main St,W Barnstable, MA Order#: G1161802 Sample Location:Description: Lab ID: 1161802 O1 Date Analyzed: 5/3/2011 @ 9:21 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Water sample meets the recommended limits for drinking water of all the above tested parameters. EPA 524.2 - Volatile Organics by GC/MS Result MCL MDL Result MCL MDL Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodifluoromethane ND 0.50 cis-1,2-Dichloroethene ND 70 0.50 Chloromethane ND 0.50 cis-1,3-Dichloropropene ND 0.50 Vinyl chloride ND 2.0 0.50 Dibromochloromethane ND 0.50 Bromomethane ND 0.50 Dibromomethane ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Ethylbenzene ND 700 0.50 1,1,1-Trichloroethane ND 200 0.50 Hexachlorobutadiene ND 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Isopropyl benzene ND 0.50 1,1,2-Trichloroethane ND 5.0 0.50 Methylene chloride ND 5.0 0.50 �1,1-Dichloroethane ND 0.50 Methyl-tent-butyl ether ND 0.50 1,1-Dichloroethene ND 7.0 0.50 Naphthalene ND 0.50 1,1-Dichloropropene ND 0.50 n-Butylbenzene ND 0.50 1,2,3-Trichlorobenzene ND 0.50 n-Propylbenzene ND 0.50 1,2,3-Trichloropropane ND 0.50 p-Isopropyltoluene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50 sec-Butyl benzene ND 0.50 1,2,4-Trimethylbenzene ND 0.50 Styrene ND 100 0.50 1,2-Dibromo-3-chloropropane ND 0.50 tert-Butyl benzene ND 0.50 1,2-Dibromoethane(EDB) ND 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichlorobenzene ND 600 0.50 Toluene ND 1000 0.50 1,2-Dichloroethane ND 5.0 0.50 Total xylenes ND 10000 0.50 1,2-Dichloropropane ND 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,3,5-Tri methyl benzene ND 0.50 trans-1,3-Dichloropropene ND 0.50 1,3-Dichlorobenzene ND 0.50 Trichloroethene 0.62 5.0 0.50 1,3-Dichloropropane ND 0.50 Trichlorofluoromethane ND 0.50 1,4-Dichlorobenzene ND 5.0 0.50 2,2-Dichloropropane ND 0.50 2-Chlorotoluene ND 0.50 4-Chlorotoluene ND 0.50 Benzene ND 5.0 0.50 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND 0.50 . Carbon tetrachloride ND 5.0 0.50 IChlorobenzene ND 100 0.50 Chloroethane ND 0.50 LChloroform 0.54 80 0.50 Attached please find the laboratory certified parameter list. Approved By: (Lab Director) �Contamin ND=None Detected RL = Reporting Limit MCL=Maevel Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of I No. zu �u t� D�� Fee BOARD OF HEALTH TOWN OF BARNSTABLE 2pprication _for Yell Con5tructiou J)ermit Application is hereby made for a permit to Construct(-J,--�A lter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel Owner Address Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well � �oc-- <s:14 .41,6 Capacity A) GPA Purpose of Well `t — Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Healt Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certifica o Compliance has en issued by the B and of Health. Signed ? 3o D5V�y Date Application Approved B 8/1 / y Date Application Disapproved or the following reasons: i Date Permit No.� �I Issued Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(Altered( ), or Repaired( ) by � 11�1g, �d2-t�-yiC nq /� ``, �— Installer ,'J at /� 9 r` f 771 Y' L(ice` e—QT `�4�PJ S 4 62-F has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private We 1 P otection Regulation as described in the application for Well Construction Permit Noel y—a2'f Dated W 8 my THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. m— ON Fee L� BOARD OF HEALTH TOWN OF BARNSTABLE - 2pplication -for Vern Congtruction Permit Application is hereby made for a permit to Construct(Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel �ILC_ Owner Address 6-u Lc_ LL�.te iC d2� OK t- r�oS 00 G 53 Installer-Driller Address Type of Building Dwelling,.,— Other-Type of Building Ao. of Persons Type of Well 4"'60 UL S-N 416 r' ` - t Capacity /U r Purpose of Well Agreement: (.,f€ - The undersigned agrees to install the afore described individual well in accordance with the provisions of the _'own of Barnstable Board of Health Private Well ProtectionRegulation-The undersigned further agrees not to place the well in operation until a Certifica e o Compliance has een issued by the Board of Health. Signed U/z/ Date Application Approved B Date Application Disapproved or the following reasons: { Date Permit No. � U V� Issued Aly h c/ Date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of (Compliance THIS IS TO CERTIFY,that the individual well Constructed Altered( ), or Repaired( by i—';e-!TrV DQ WF_L(( dZlLL/�G Installer at /� /kD "GZ cam " �� C� S7A 6Z-tc 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 No/A)&/ Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Veil Con5tructton Permit No. dZ-y Fee Permission is hereby granted to - {�b�J1) �h�'.L- 6�IL.L/)(l(�S Installer to Construct Alter( ), or Repair( an individual well at: No. M o-(" &-F Street ll ^^�� as shown on the application for a Well Construction Permit No.w 20I Li CZq Date Y J Date Approved By � r AsBuilt �# Page 1 of 1 �{I JC TOWN OF BARNSTABLE 7 LOCATION f f�-' y ��/fir,t S SEWAGE # / VILLAGE ASSESSOR'S MAP & LOT l UUl INSTALLER'S NAME & PHONE NO� N =Fif i - L1L 7 7�g SEPTIC TANK CAPACITY t ed LEACHING FACILITY{cypel �n 1�•f aA 5 NO.OF BEDROOMS 3 1VATE WE OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: g� DATE COMPLIANCE ISSUED: �� VARIANCE GRANTED. Yes No �ctd CO f i http://issgl2/intfanet/propdat ,/prebuilt.aspx?mappar=111001&seq=1 7/29/2014 TOWN OF BARNSTABLE LO :ATIONf. SEWAGE 7 v! VILLAGE ASSESSOR'S MAP & LOT!//- 00/ INSTALLER'S NAME PHONE NO.Jra( SEPTIC TANK CAPACITY z"0000 LEACHING FACILITY:(type) 41 g6 1� � brie F(size) NO. OF BEDROOMS 3 IVATE WEL OR PUBLIC WATER BUILDER OR OWNERv�c� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No \ / C.0 r A / TOWN OF BARrNSTABLE 11.0�'JATION �� /�� ► /�'Qi"'5��� SEWAGE # VILLAGE ' � ' ASgESSOR'S MAP & LOT J. CRAIG ME 4 INSTALLER'S NAME PHONE NO. 78 LINDEN ST. SEPTIC TANK CAPACITY,/ 0 HYANNIS, MA 02601 LEACHING FACILITY:(type) (size) NO. OF BEDROOMS IVATE WEL OR PUBLIC WATER BU4LDER elrOWNER o#i'1d0 d DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �� VARIANCE GRANTED: Yes No � � � � i `� / fl / `�;I� .. . � � �� _ ®� Y _ � �- . 1 �, _ � � r ,� �?� f�:.�,i •,��.pp. _ � No.. .R.:...�'A.7 Fis .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH G`'`' .........OF..... ........... ..................................... Allp irFation for lhgpoii al Workii Tnnitrur lon amit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at• J ..........� l!✓ -• ---•--------------------•---..........---•• ....•• ............ - ._. ... ----•- tion-Address t N WL ---- ----- -- -- -- ---- -- W O ner d w d es� a .. ...-••---••••-•----•-•--- Installer Address Type of Buildin Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ......-••----••-••......•---•••. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.,.............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet_................. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_................. Pr' ODescription of Soil...... .......................•-------------------------------------------------------------------------------------------- x W -•••------•--•--••----------•-••---••------••-•-•---•--------------•----------------•--•----------- .... U Nature of Repairs or Alterations—Answer when applicable,��. C;r --- --- ---- •--•-••---•-•-- ` .. .. . .- -- -----------•------------------------------•---- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disp sal System in accordance with the provisions of TITTIE $ 5 of the State Sanitary Code—The undersigned further agrees not to place the system i operation until a Certifica"te of Compliance hasLeni.ssby the boa d of h lth. Signe • ... ....._••-•.....---•- -----•......--- � --- ------•-•--•----- Date Application Approved By------.... ' - ------------------- ....... .-.5..^_�5.�.._. Date Application Disapproved for the following reasons-----------------------------•-------•--•---------------------------------------...---...._...-•--------------•-- --------------------------•...•-----------------------------.......--•--••......----•----------•---•••---...---------•--........_•-•---------•-•---•---------•-----•-•--------_.....- ...--•--•-•--- Date PermitNo......��.-n... Y .................. Issued-....................................................... Date f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..--f'�.°,� "..:`.........OF...... ..:...:�!-��:,_-.€; ................................. Appliratiou for Disposal Works Toustrnr�ttun Permit Application is hereby made for a Permit to Construct ( ) or Repair (0A an Individual Sewage Disposal System at: ........... -....;; ................................................. _...-•--•---•-•-•................•-------••-.....•--------..._-- .......-•--•-_.....•-•------ �1:oaation-Address l/ a (or t No:, - �" +J^ .._:....--•------��.. ..._.;a:`:A,.,...�0w.................................................. ne�°.`......U-- ;- -----•-•--... ...........................................! f ... 1 Address----------------�...............----.. a y - -! �... .,E -L� '""P I.SIi'✓ T............`'t0:•!'• / C �^....................... \ %�,i Installer Address �J d Type`°of Buildings Size Lot............................Sq. feet V Dwelling—No. of Bedrooms________________________________ _____Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ____________________________ No. of ersons._.______._.____._._________ Showers — a YP >lg P ( ) Cafeteria ( ) � Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................. Diameter................ Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 04 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---_------------------ �Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ o <,. ............................... -------------------------------------------_________...___------------.._____-_______---------------_-------------- Descriptionof Soil----- __ :: . .: =---------------------•----•--------------------------------------•---------------------------•-----••--....._-------- W ..............._............................................................_.............................._ d --r_._ ........e-a__.,_.____---_?_-_--"""-"'� ?-� WU Nature of Repairs or Alterations—Answer when applicable blk �C.�.,�1- •'?�'' :�'"�'%�'"~9"- --r ------- ---- -..._•••------- Div -------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disp al System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in.,-' operation until a Certificate of Compliance has been issued by the.bboar� of health. Signed.!:)_---------•-••------- .........=--------......................................... --- ".--•-••-....._--•------- 1 1 Date Application Approved BY ,�! ._... ---•----�-- � Date Application Disapproved for the following reasons:.............................................................................................................. ..............................•-------....--•-•-._...--------...--••----------•-•-------...._..----•---•-•-----------•-------••-•-------•--••--•-----------•-----•----••..._---•-••-----•----------_..._ Date PermitNo.-----0..a...n----3-y 7-------------•--- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, n �...........�-.......»«..'i �'.`ff�+•..z�nC.:.... ..€..., Tntifirab of Tnutpfiattrr THIS IS TO CERTIFY, That the Individual-Sewage Disposal System constructed ( ) or Repaired ( ) by----- -----------• -- /............................................---=� - 1 F= C t�- Installer ------------------------=------------------------------------------------------•---•--•••--•- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......... ._.. dated-............................................... THE ISSUANCE OF THIS'CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS _ �QARD,OFi HEALTH �© OF .................................................... FEE..... No._ ..Y._7 aL.( .--- Dispos tl-Turks Tontrnrtinn runfit Permission is hereby granted_N __.______.'5*- "' _.__:.k7 _ %'_..1_�' ri ...................................... to Construct ( �) or Repair (4--`)ari Indiy�ua� �e vage Disposal,System y /1 at No.•----/0--"'� f y'( � - ................... •-••••-••-•--•.............•--•-----....---••----•--•------------- ' �reet / ` as shown on the application for Disposal Works Construction Permit No ff-j3��_7___ Dated........................................ 1. ___________________________ V Board of Health DATE....=...............�..-"_---1--....--�.� FORM 1255 HOBBS & WARREN. INC., PUBLISHERS AsBuilt Page 1 of 1 X TOWN OF BARNSTABLE LOCATION ` f f N��r nni%1 S�. SEWAGE # 7 ` VILLAGE7k1 r✓15;�� ASSESSOR'S MAP & LOT l INSTALLER'S NAME PHONE NOT 0 ` SEPTIC TANK CAPACITY ib . 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