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Home My WebLink About0260 PERCIVAL DRIVE - Health '260TERCIVAL DRIVE;X A.= 110 001.024 bit I e Ii I 1 I I e � ENVIROTECH LABORATORIES,INC. MA CERT.NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name: Culligan Location Address: PO Box 2070 260 Percival Sandwich, MA Barnstable,MA 02563 Lab Number: DW-220073 Collected By: Andrew Biarichette Date Received: 01/06/22 Sample Type: Kitchen Well Specs Locstien Source s. 1?ate Collected, . :rMMWe CaAected its Analysis Requested Units Recommended Limits Analysis Result Method Date Analyze Analyzed By Total Coliform CFU/100mL 0 0 SM9222B 01/06/2022 KF aQ 17:00 pH pH units 6.5-8.5 6.41 SM 4500-H-B 01/06/2022 SD Specific Conductance= umhos/cm 500 161 EPA 120.1 01/06/2022 SD Nitrite-N mg/L 1.00 <0.006 EPA 300.0 01/06/2022 SD Nitrate-N mg/L 10.0 1.45 EPA 300.0 01/06/2022 SD Sodium mg/L 20.0 17 EPA 200.7 01/16/2022 KB Total Iron mg/L 0.3 <0.01 EPA 200.7 01/16/2022 KI3 Manganese mg/L 0.05 <0.005 EPA 200.7 01/162022 KB Potassiumn mg/L 20.0 1.3 EPA 200.7 01/162022 KB Calcium mg/L NIA 9.0 EPA 200.7 01/162022 KB Magnesiumn mg/L N/A 4.1 EPA 200.7 01/162022 KB Total Hardness= mg/L 50-200 39 SM 2340 B 01/212022 KB Alkalinity mg/L 200 38 SM 2320E 01/06/2022 SD Sulfate mg/L 250 6.2 EPA 300.0 01/062022 SD Chloride mg/L 250 29 EPA 300.0 01/062022 SD Turbidity NTU 5.0 <t SM 2130B 01/062022 SD Color= APC units 15 <5 SM 2120B 01/062022 SD Free CO2 mg/L 50 49 Calculation 01/072022 SD Date 1121/2022 Ronald J.Saari Laboratory Director BRL=Below Reportable Limits `See Attached Page 1 of 2 ❑Cert fication is not available for this analyze for potable water samples.. I ENVIROTECH LABORATORIES,INC MA CERT.NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(SO8)888-6446 Client Name: Culligan Location: Address: PO Box 2070 260 Percival Sandwich, MA Barnstable,MA 02563 Lab Number: DW-220073 Collected By: Andrew Biarichette Date Received: -01106/22 Sample Type: kitchen Well Specs LOCASen Source Date Collected lbw Collerkd Conmertts A Q t1O5122._ 16,00 Analysis Requested Units Recommended Limits AnalysisResultj Method IDateAnalyzedl Analyzed By Comments: pH is below recommended limit and may have corrosive characteristics. Total Hardness results indicate water is soft. All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. Water meets EPA standards and is suitable for drinking for parameters tested. Date 1/21/2022 Ronald J.Saari Laboratory Director BRL=Belaw Reportable Limits *See Attached Page 2 of 2 ❑Certhcation is not available for this analyte for potable water samples., ENVIRO TECH LABORATORIES,INC. MA CERT. NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name: All Cape Well Location Address: PO Box 126 260 Percival Drive Brewster,MA Barnstable,MA 02631 Lab Number: DW-220235 Collected By: Client Date Received: 01/25/22 Sample Type: Well Specs Location Source Date Collected hme Collected Comments A 01126/22 9:55 , Analysis Requested Units Recommended Limits Analysis Result Method Date Analyzed Analyzed By Total Coliform CFUM00ml- 0 0 SM9222B 01/25/2022 AC @ 13:30 pH _ pH units 6.5-8.5 7.13 SM 4500-H-B 01/25/2022 SD Specific Conductancen umhos/cm 500 156 EPA 120.1 01/25/2022 SD _^ Nitrite-N T m_ mg/L 1.00 F <0.006 EPA 300.0 01/25/2022 SD Nitrate-N mg/L 10.0 1.4 EPA 300.0�01/25/2022 SD Sodium mg/L 20.0 17 EPA 200.7 01/26/2022 KB Total Iron mg/L 0.3 <0.01 EPA 200.7 01/26/2022 KB _ Manganese mg/L _ 0.05 <0.005 EPA 200.7 01/26/2022 KB Volatile Organic Compounds* ug/L _ See comment. See attached EPA 524.2 01/26/2022 NEC* Comments: *Trace to low levels of chloroform are occasionally detected in ground water in coastline areas. All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. Water meets EPA standards and is suitable for drinking for parameters tested. Date 1/27/2022 Ronald A filLaboratoryor BRL=Below Reportable Limits *See Attached Page 1 of 1 aCertiftcation is not available for this analyte for potable water samples.. f New England Chromachem 6 Nichols Street Salem,MA 01970 978-744-6600 Sample Information EPA Method 524.2 Rev 4.1 Volatile Organic Compounds in Water Lab ID: 201525 Client: Envirotech Laboratory,Inc. Client ID: DW-220235 State: Liquid Date Sampled: 01/25/22 Date Received: 01/26/22 Date Analyzed: JOV26122 MCL Regulated VOC's Results(ug/L) (ug/L) Unregulated VOC's Results ugiL) Benzene ND 5 Acetone' ND Carton Tetrachloride ND 5 Bromobenzene ND 1,1-Dichloroethene ND 7 Bromochloromethane ND 1,2-Dichloroethane ND 5 Bromodichloromethane ND 1,2-0ichlorobenzene ND 600 Bromoform ND 1,4-Dichlorobenzene ND 5 Bromomethane ND Trichloroethene ND 5 2-Butanone ND 1,1,1-Trichioroethane ND 200 N-Butylbenzene ND Vinyl Chloride ND 2 Sec-Butylbenzene ND Chiorobenzene ND 100 Tert-But benzene ND cis-1,2-dichloroethene ND 70 Chloroethane ND trans-1,2-dichloroethene ND 100 Chloroform 0.97 1,2-Dichloropropane ND 5 Chloromethane ND Ethylbenzene ND 700 2-Chlorotoluene ND Styrene ND 100 4-Chlorotoluene ND Tetrachloroethene ND 5 Dibromochloromethane ND Toluene ND 1000 1,2-Dibromo-3-Chloropropane ND Xylenes(Total) ND 10000 1,2-Dibromoethane ND Methylene Chloride IND 5 Dibromomethane ND 1,2,4-Tdchiorobenzene ND 70 1,3-Dichlorobenzene ND 1.1,2-Tdchloroethane IND 5 Dichioroditluoromethane ND 1,1-Dichloroethane ND Acetone Detection Limit=10 ug/L 1,3-Dichloropropane ND ND=<Method Detection Limit 2,2-Dichloropropane ND NA=Not Analyzed 1,1-Dichloropropene ND MRL=0.5 ug/L cis-1,3-Dichloro ropene ND Dilution Factor= 1 trans-1,3-Dichloro ro ns ND Hexachlorobutadiene ND Isopro benzene ND P-1sopropyltoluene ND Meth -tert-butyl ether ND Naphthalene ND N-Propylbenzene ND 1,1,1,2-Tetrachloroethane ND 1,1,2,2-Tetrachloroethane ND 1,2,3-Tdchlorobenzene ND Trichlorofluoromethane ND 1,2,3-Trichloropropane ND 1,2,4-Tdmethylbenzene IND 1,3,5-Trimethylbenzene IND Surrogate Standard Recoveries % Benzene-d6 95 MCL TTHM's=80 ug/L 4-Bromofluorobenzene 95 Method Detection Limit=0.5 ug/L 1,2-Dichlorobenzene-d4 104 Analysis performed per 310CMR42 Electronically signed and approved by Mr.Bruce A.Bornstein,Lab Director Date: 1/27/2022 . Department of Environmental Management/Division of Water Resources WATER WELL COMPLETION REPORT WELL LOCATIONS GEOGRAPHIC DESCRIPTION Address N S E W of (feet) (circle) City/Town Well owner 20 14�� ," � � (road) Address d + �1)_y� 9 N S E W of (mi.in tenths) (circle) Board of Health permit: yes OI-' no ❑ intersect. w/ (road) WELL USE �/� WELL DATA Domestic P" ubhc❑ Industrial ❑ Total well depth 46 r ft. Monitoring❑ Other Depth to bedrock ft. Water-bearing rock/unconsolidated material: Method drilled H Date drilled — Description Water-bearing zones: CASING f j � 1) From y To Type �/. 2) From To LengthI55� ft. Dia(.I.D.) 4/ in.. 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: S Screen: dia. Grout_❑. Other Slot# fb length$f�from tt. i PUMP TEST r GG Static water level.below land surfaced ft. Date Drawdown�- ft. after pumping Al lir. min.ate/s2 gpm How measured Recovery ft. after —hr.—min. 0 LOG of FORMATIONS COMMENTS Materials From To Q (� ty Driller Mass. Registration# / d Firm ✓. Address { f� 1-h j City/Town e � Si nature o/supervising registered well driller Please Print firmly - _•_ BOARD,Of.-HEALTH COPY , , OWN OF BAR.NSTABLE C.AfION LiBr SEWAGE # VILLAGE. VJ ASS' SSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. EPTIC TANK CAPACITY 1.0-0- Z—�!) LEACHING FACILITY:(type)_ (size) cs� Cp - ENO. OF BEDROOMS PRIVATE WELL 0 PUBLIC WATER BUILDER lzDATE PERMIT ISSUED: 3 l � DATE COMPLIANCE ISSUED; VARI.A.NCE GRANTED: Yes No y 1f � �. �, S 1 `` .,' b w �11 •� � , f'j ' I ' �� i � l �� ' � � I• i �. P��*4 No.--- ' ✓-'-- --- -- /Ir Fee-,;Zor----'--�-�----- BOARD OF HEALTH TOWN OF BARNSTABLE ZippYicat ion-*rVelt Con5tructioni9ermit Application is hereby made fora permit to Construct ( ), Alter ( ), or Repair ( "andividual Well at: h -------------------------------- -------------------------------------------------- Location Address Assessors Ma--and Parcel --- ----------------------------------- Owner Address Installer.— Driller 1_ Address Type of Building Dwelling--------,-------)------------------------------------------------- Other - Type of Building —----------- No. of Persons------------______�^ Type of Well- -- .�- x= L— - YP ----------- Capacity---------------------------- Purpose of Well--------------------------------------- --- 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 a Certificate of Compliance has been issued by the Board of Health. Signed ----- --- , date — Application Approved By--,-- date Application Disapproved for the following reasons:--- -- ---- — — ------------------------------------------------------------------------- - — �� Ada to Permit No.------- "-- --- -� �'' ------------------ Issued ----------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Comphante THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or.Repaired ( ) by_1- _' _1 �i fir✓_ -- ---_- -- --------------------------------- ----- - ---- ---- Installer at--- ------- /`'- ttv - - - 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 *` E- ' - DatedTHE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------=---------------------------------- ---------------------- Inspector f 16 'NO.- --------_�_ •• f Fee- , BOARD OF HEALTH TOWN OF BARNSTABLE Apprigtion.-*rVell Congtructionpermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (cv)an individual Well at: - ------- ------------------------------------------- ------------------------------------------------ Location — Address Assessors Ma and Parcel ✓1 Gay t r ----- 7-� ► -. -- — -- - —----------------- 1 owner }� address Installer — Driller G Address Type of Building Dwelling------------------------------------------------------------------- Other - Type of Building ----------- No. of Persons-------------------------------------------------------- Type of Well---------- fit p_Gt� L -'=--- apacit Purposeof Well------------------------------------------------------------------ r 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 a Certificate of Compliance has been issued by the Board of Health. Signed-�;. =� _ _ — 1/'r --- —�----- date Application Approved By-- Application Disapproved for the following reasons:-----—------------ —date -----------------------------------------------------------------------------------------------------------------_------- -- -- - - --- -------- p date Permit No.-----7�`--L '� �'- - — - Is ed—=--=_ -`= '!= '`'— --------- ... —date...- r BOARD OF HEALTH TOWN OF BARNSTABLE �-ertifitate ®f �om�riar�te THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by---/' -----------------1��f -:�!�'----------------------------------------------------------------- ----------------------------------------------------------------------- Installer at- r�'�-`� -�`� -_ -!__!c' _��U° -1 ----------- ---' c�= �l_5_I A .A1�=-------1� 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 �s-0,7-----/'Dated--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------r-------------------------------------------------------------- Inspector-------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE eil 'on5truct ion Permit No. Fee �✓__/l%� Perntissr`7r is Thereby granted--- ---------------------------------------- __ to Construct ( 4), Alter ( ), or Repair ( ) an Individual Well at: No. ----------------------------------------------------- ----------------------------------------- --------------------------------------------- ----------------------------- Street as shown on the application for a Well Construction Permit l.Ar" 9 *" No. Dated - ----='� �`' Board of Health DATE--------------------------------------------------------------------------------------- -�-71 , �� 0 i9 a 5 \ i 0 ?16 +12 g y Pe> 46 �•t�J�OSt t7 _ ' 6' u? Peck... � II ip,T �.., opc�1 CF �d PiTER a� t SULLIVAN IMMAM PARTS No. 29733 .. �NIL U-14 c-A �" � � -� � -per/ �-a� � o� NoFmc.....I........................ THE COMMONWEALTH OF MASSACHUSETTS 141 f BOARD OF HEALTH cot r..............OF...............j2la.rr).5 6_.W�� Appliration for Ditiposal Workii Tomitrurtivit ran fit Application is hereby ma 1.rrl ) or Repair an Individual Sewage Disposal System at: n� P', it to Construct ( --------- ---- Ea W...1$...... .................................LA.......*1.................................... .......... , Location,-.A ;e,F or Lot No. __ftYV ......................... ............................................ ........................................... Owner Address / .-H. ..... ......................... .................................................................................................. Installer Address Type of Building Size Lot.3 ,..rl ....Sq. feet U .3 Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder a P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4Other fiyt es ...................................................................................................................................................... Design Flow...........................................gallons per person per day. Total daily flow................_334)...............gallons. 1:4 Septic Tank—Liquid capacity]IW..gallons Length................ Width.............--- Diameter................ Depth................ Disposal Trench—No. .................... Width................... Total Length.....--............. Total leaching area....................sq. ft. Seepage Pit No....... .... Diameter.......JDI----- Depth below inlet........k,........ Total leaching area...Z(4�...sq. f t. Z Other Distribution box 6,,y Dosing tank ( ) Percolation Test Results Performed by---------------- ... Date......-'.193.-A a ....... Test Pit No. I................minutes p�rk nch Depth of Test Pit---.--..........--.. Depth to ground water..------................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ................ -------*-------------------------------------------------------------------------*----------- ------------ ... S......... -------- i P) i .......................... 0 Description of Soil...........0.— Z.......... 0- ----------obsla).L--------------- .................................... ...... .............P.m,0_51.4�-kq....--a t d L............................................................................. ........................... . ..................... -----------------------------", " .. - A .... ........... ........Ify,. ._�.K...1. -_+ - ___j U Nature of Repairs or Alterations—Answer wh n applicable................. .............................................................................. ................................................................................. ............................................................................................................... Agreement: I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the o. -ealth. Signed --------- ..... ----------- -- ---- Signed ka—,L—-- -------- -------------------- ---- ------------ ----- D�t Application Approved By . ............... ----- ---------------- ... . ..................... ?'7 . .. ............ ....... ..............4� .... - -- -------- Application Disapproved for Pthe following rear .......................................................................... - -------------------------------------- --------�3.......... .........................................................................---------------------------............ ............ ............... / Dace Permit No. --- ----- -- ----------- -------- Issued ...... 3_------........ No.. ........... ....1 �J !....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... .. . .....----..OF............. >_K-5.r: �!'�A b)'()..--.._........t...._---.---.------.. � Appliration for Disposal Works Toustruriun rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -� Location-Address or Lot No. ----•.................--•--.........--••---•-•--........---•-•--•---............................. ..........--...................................................................................... _ Owner n Address W { l CS-�Z.4t7= _ � 7 Installer t Address Type of Building Size Lot..3&,_t..rl2....Sq. feet 1., Dwelling—No.. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 4 Other—Type of Building No. of persons............................ Showers — Cafeteria P4 Other fixtures -•--••......-•-••---••••------•. . W Design Flow................. �..............._..__gallons per person per day. Total daily flow.................- & ?...............gallons. WSeptic Tank—Liquid capacity_1-00.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area-_____---.__._•-----sq. ft. Seepage Pit No-------_1........ Diameter.......)V..... Depth below inlet................. Total leaching area... ...sq. ft. Z Other Distribution box ( (,,,,y Dosing tank ( ) ~' Percolation Test Results Performed by................. ... Date Date...._'"-:2 J.: . '......... -- aa Test Pit No. I................minutes per inch Depth of T'est Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit-_-___-_--_______.__ Depth to ground water-.-_-______-___-___-_-_. a ---•••......---•-•------•------- . -:-•••--------------•-•••---------------•-----...---.......-•---------•-----------•---•--..........•--..••-- D Description of Soil----•-•_-•--n -�/ ••---•. --------- V ............................................. ............. .--•-----------••-•-----•• -••---..--.......--•-----••--•-----•--••- UNature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------------------------------------------- -----•-•••-•••----------------•---------------------------------•--------•••••----•••....-----•-•---•---••--•-•-•-••-•---.....•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board-of health. Z f %`'�1 Signed � U' �' `s. 1 1 ' n -------------- - Application Approved BY .... � /�-=------ ----�------�--------'---'----------?----------%---�---- ................--------- -----=- /-------- 1 Application Disapproved for the following reasons: ............................................................... ............----------.. ---. .---- ----------. ------ .................................................... � �, .�.....f....----' �_�------Dare.................. Permit No. ....... fJ ` f L� ....,,. ..f.�' '...:......: .....:.. Issued --...... ) ! f Date • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --....[0..L .1.71............... of _-------------?��r l�.`,�rt..�f e................................... Ter#tftca to of Tomplta ltre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) l Installer � J J at . -- .: .--........:�('C!...(�Ct::�....1. ` c... ...............� .. s - has been installed in accordance with the provisions of TITLE 5 of jThe States Environmental Code as described in the application for Disposal Works Construction Permit No. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ........... ................... Inspector .... �.�:. �--- .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH " l - sue' I��Cr r'; �- 1 �'' ,- f No. ` 1 !`.� " FEE..:::............. Disposal Works %T11notratrtion rrutit Permission is ereb ranted----•---------- -•-----•--•-•--•••..•--- --•----•••--------•-•-------------••-•--•-••••-•-•--------•-•--•-•-•-............--------------•-- Yg to Construct ( or Repair ) an;In v idu {S�ew�a,( Disposal Sys t C, 1 Street as shown on the application for Disposal Works Construction Permit No.-L., _.o_' _! Dated............_::__. ...................... �✓ Board of Health DATE...... _ == ----------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS slE.t.% E�My' I ` �Z �b(t r 1 0 _ v >C�Sp"o9 d95 DlSPoSA IDPIT �Dod SAL. 12� sly -SEE `�C�4�1 orJ BAGk �IEa.��= 41 BOTTOM: 0 7g `. .,:7g , T'aTAL- ,16tJdg 62, l T?E2�ac.a-t-tot;i .. A- OzL'E95 _.. V/E6T ISA1Z1�25MBt... _ U` � f CF F$ Ztl OF M oy i PETER `a enxTEw o SULLIVAN .� �. No.�29733 : BOA, FC/sTETF A� �$A . J - —err- --...... -- r� Tip v 5�, o low wt/•P v C = /N✓. 2'�: . PKT nV✓ 6M, t P�Sr�+J i ti rrc ass � ue . :A cbo ' � es r L B N� B Z BBC �,�-y �l: Tti t / P, SarJ�. STour= �v MPA�� - Sp� 77 -t i�* -7- W 17Z1 z :6 .;'12. .. . 14AP 1lo R, 1�?•d- 2v46 �� 3olI�'IS Vst. J lld �E�f-IFIU PLOT RAiJ d Z Iwva�� o n . . .. Loc�r►ocl____ �c/E�I' `�r��J 5`i'A�,t.� Sc L, �tz�os� P�AI.I R :- 2�� S•Io•�3 17 CiFY. TEAT ,,gow IJ HezeoN - off...�Arz c ��IUU ►S or( oa v,/ Tt11S � IS Nor :�3�iE� oN AtJ 1�15T1�t1ti4ElYl �u2vc�j �rJD rH� OFF5ET5 4�4ovi� u ur .'(3E o PaZl1J�L-CI%, l :T'o G ,FABI_15N e2_ ` titAS� . APP L.I cA N;7-; TAeTA t.1 fJ C_ T i , 20 4!903 �CL7f l , t r : Zlvr r , k I �77. Ov dL : : 1 , / + '``—=� - `.::�-�� k �., ''., ,, :� ' � AXIS• � i(T' r I' , e Tyr � - i' ,^ , r r i 1 I1+1 ��r.r� �\ Qr� � r t Dpcz�1 , 1 L i. PATER t tJ�LU Lb4miA OF V eut of l..�T t1..7 I ! u SULLIVAN , I ' N0. 29733 DCES la0[ IW I C14 kliT +J a e o �1� i0��G�STER�,�� Log Number: Bottle T BC992 Date: May 24, 1993 BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE BARNSTABLE, MASSACHUSETTS 02630 O� � � s NYA5� DRINKING 'WATE? LABOPs.TORY ANALYSIS PHONE: 362.2511 Ext. 337 Client: Tartan Inc Collector: C Stiefel Mailing Address : P 0 Box 1198 Affiliation: BCHED West Chatham MA 02669-1198 Time & Date of - Collection: 5/20/93 12:35 p.m. Telephone: Type of Supply: we Sample Location: Lot 47 Percival Lane Well Depth: West Barnstable MA Date of Analysis : 1:30 p.m. PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100'ml I 0 0 off I 6.4 � l Conductivity (micromhcs;cm) i 90 i 500.0 Iron (oom) I <.1 I 0.3 Nitrate-Nitrocen (ppm) I <.1 I 10 .0 Sodium (ppm) 8 20.0 Copper (ppm) < <.1 1 .3 i XXX Water sample meets the recommended limits for drinking of all above tested parameters . ii . Based only on results of the parameters tested for this sample, the water is suitable for drinking but may present the problems checked below: A. ';dater sample has higher than average levels of Nitrate. Future monitoring is recommended (2-3 times per year) to establish any upward trends . B. .he low pH of the water may shorten the useful life of the house's plumbing . C. Water may present aesthetic problems (taste, odor, staining) due to 0. Water sample has high levels of sodium. Persons on low sodium diets should consult their doctor. iII. ' Due to one or more of the reasons checked below, this water sample exceeds the recommended maximum contamination level for drinking water: A. High Bacteria B. High Nitrates REMARKS: CC: BOH CC . 1 17I85 Laboratory Director I ( BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT LABORATORY REPORT VOLATILE ORGANIC CHEMICAL ANALYTICAL RESULTS Client: TARTAN INC Collection Date: 05/20/93 I Mailing Address:P 0 BOX 1198 Date of Analysis : 05/21/93 WEST CHATHAM MA 02669 Type of Supply: WELL Well Depth (FT) : Not Given Telephone: Sample Location:47 PERCIVAL LANE LAT. (DDMMSS) : Not Given BARNSTABLE LONG. (DDMMSS) : Not Given Collector: C STIEFEL Map/Parcel : Affiliation: BCHD Analytical Method: 502 .1=1 , 502 .2=2 , 503 . 1=3 , 504=4 , 524 .1=5, 524 . 2=6 , 502 .1/503=7 Contaminants Anal . Result MCL Detection Detected Meth. ug/l ug/1 Limits (ug/1) --------------------------------------------------------------------- Chloroform 2 5. 4 0 . 5 Only those compounds listed above were detected. Attached is a list of compounds for which this sample was analyzed. NOTE: Contaminant levels equal to or exceeding the Detection Limits are reported. MCL means Maximum Contaminant Level for EPA-regulated compounds . (ug/1 = micrograms per liter = Parts Per Billion) The Environmental Protection Agency has set Maximum Contaminant Levels (MCL) for the following compounds . This sample compares as follows: COMPOUND MCL (in PPB) Benzene 5.0 * level not exceeded * Carbon Tetrachloride 5.0 * level not exceeded * 1 , 2-Dichloroethane 5 . 0 * level not exceeded * 1 , 1-Dichloroethene 7 .0 * level not exceeded * 1 , 4-Dichlorobenzene 75 * level not exceeded * . 1 , 1 , 1-Trichloroethane 200 * level not exceeded * Trichloroethene 5 . 0 * level not exceeded * Vinyl Chloride 2. 0 * level not exceeded* Comments or additional compounds found: Thomas F. Bourne , Laboratory Director ,Log Number: Bottle # 6C992 Date: May 24, 1993 04 �'sa BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT F` SUPERIOR COURT HOUSE Cam` BARNSTABLE, MASSACHUSETTS 02630 MASs � DRINKING WATER LASCRA.TORY ANALYSIS PHONE: 362-2srt Ext. 337 Client: Tartan Inc Collector: C Stiefel Mailing Address : P 0 Box 1198 Affiliation: _ BCHED West Chatham MA 02669-1198Time & Date of Collection: 5/20/93 12:35 p.m. Telephone : Type of Supply: well Sample Location: Lot 47 Percival Lane Well Depth: West Barnstable MA Date of Analysis : 5/20/93 1:30 p.m. PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100'ml I 0 0 oI: 6.4 Conductivity (micromhos/cm) i 90 i 500.0 Iron (pom) I <•1 ! 0.3 Nitrate-Nitrogen (ppm) <.1 ! 10.0 _ � v Sodium (pom) I 8 20.0 Copper (ppm) <.1 1 .3 I XXX Water sample meets the recommended limits for drinking of all above tested parameters . Ii . Based only on results of the parameters tested for this sample , the water is suitable for drinking but may present the problems checked below: A. Water sample has higher than average levels of Nitrate. Future monitoring is recommended (2-3 times per year) to establish any upward trends . S. The low pH of the water may shorten the useful life of the house's pl umbing . C. Water may present aesthetic problems (taste, odor, staining) due to 0. Water sample has high levels of sodium. Persons on low sodium diets should consult their doctor. III. Due to one or more of the reasons checked below, this water sample exceeds the recommended maximum contamination level for drinking water: A. High Bacteria B. High Nitrates REMARKS: CC: BOH C C : ut,.......� Laboratory Director 1171R5 i BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT LABORATORY REPORT VOLATILE ORGANIC CHEMICAL ANALYTICAL RESULTS Client: TARTAN INC Collection Date: 05/20/93 Mailing Address :P 0 BOX 1198 Date of Analysis :05/21/93. WEST CHATHAM MA 02669 Type of Supply: WELL Well Depth (FT) : Not Given Telephone: Sample Location: 47 PERCIVAL LANE LAT. (DDMMSS) : Not Given BARNSTABLE LONG. (DDMMSS) : Not Given Collector: C STIEFEL Map/Parcel : Affiliation: BCHD Analytical Method: 502.1=1 , 502 . 2=2 , 503 .1=3 , 504=4 , 524 . 1=5, 524 . 2=6 , 502 .1/503=7 --------------------------------------------------------------------- Contaminants. Anal . Result MCL Detection Detected Meth. ug/1 ug/1 Limits (ug/1) ----------------------------------------------------=---------------- Chloroform 2 5. 4 0 . 5 Only those compounds listed above were detected. Attached is a list of compounds for which this sample was analyzed. NOTE: Contaminant levels equal to or exceeding the Detection .Limits are reported. MCL means Maximum Contaminant Level for EPA-regulated compounds . (ug/l = micrograms per liter = Parts Per Billion) The Environmental Protection Agency has set Maximum Contaminant Levels (MCL) for the following compounds . This sample compares as follows : COMPOUND MCL (in PPB) Benzene 5.0 * level not exceeded * Carbon Tetrachloride 5.0 * level not exceeded * 1 , 2-Dichloroethane 5.0 * level not exceeded * 1 , 1-Dichloroethene 7 .0 *. level not exceeded * 1 , 4-Dichlorobenzene 75 * level not exceeded * 1 , 1 , 1-Trichloroethane 200 * level not exceeded * Trichloroethene 5.0 * level not exceeded * Vinyl Chloride 2.0 * level not exceeded * Comments or additional compounds found: Thomas F. Bourne , Laboratory Director a= ,r i- BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT LABORATORY REPORT VOLATILE ORGANIC CHEMICAL ANALYTICAL RESULTS 13jl Client: TARTAN INC Collection Date: 05/17/93 Mailing Address:P 0 BOX 1198 Date of Analysis :05/20/93 WEST CHATHAM MA 02669 Type of Supply: WELL Well Depth (FT) : Not Given Telephone: Sample Location:14 PERCIVAL LANE LAT. (DDMMSS) : Not Given BARNSTABLE LONG. (DDMMSS) : Not. Given Collector: C STIEFEL Map/Parcel : Affiliation: BCHD Analytical Method: 502.1=1 , 502 . 2=2 , 503 . 1=3 , 504=4 , 524 .1=5, 524 .2=6 , 502.1/503=7 -------------------=------------------------------------------------- --------------------------------------------------------------------- Contaminants Anal . Result -MCL Detection Detected Meth. ug/l ug/1 Limits (ug/1) --------------------------------------------------------------------- Chloroform. 2 1 .0 0. 5 Only those compounds listed above were detected. Attached is a list of compounds for which this sample was analyzed. NOTE: Contaminant levels equal to or exceeding the Detection Limits are reported. MCL means Maximum Contaminant Level for EPA-regulated compounds. (ug/l = micrograms per liter = Parts Per Billion) The Environmental Protection Agency has set Maximum Contaminant .Levels (MCL) for the following compounds . This sample compares as follows : COMPOUND MCL (in PPB) Benzene 5.0 * level not exceeded * Carbon Tetrachloride 5.0 * level not exceeded * �., 2-Dichloroethane 5.0 * level not exceeded * 1 , 1-Dichloroethene 7 .0 * level not exceeded * . , 4-Dichlorobenzene 75 * level not exceeded 1 , 1 , 1-Trichloroethane 200 * level not exceeded * Trichloroethene 5.0 * level not exceeded * V-Lnyl Chloride 2 .0 * level not exceeded * Comments or additional compounds found: + Thomas F. Bourne , Laboratory Director �I Department of Environmental Managernent/Division of Water Resources a i WELL COMPLETION REPORT WELL LOCATIOU U GEOGRAPHIC DESCRIPTION Address / �G �Pr 4r c�4 ID l ' N 4 E W of (feetl (circle) City/Town a rry Src r /fit a 16l, Well owner '✓t r`V 7 O (road) Address S Q dia ti(f�t s T- N E .W of W y l C Q S To/ /Lt G U I h O y (nri.in tenths! Iclrcle,I intersect. w/ 0/D Lo`r:+l'Y /?J. Board of Health permit obtained: yes IT no ❑ (road) WELL USE WELL DATA t Domestic � Public❑ Industrial E] Total well depth ft. Monitoring❑ Other Depth to bedrock' _ ft. Water-bearing rock/unconsolidated material: Method drilled�'�'G� // Date drilled 13 Description Water-bearing zones: CASING Type SC l r tV w � 1} From To rr Length �O It. Dia(.L yD.) in. 2) From To 3) From To Length into bedrock—ft. Gravel pack well: dia. Protective-well seal: Screen: dia. t 'GrouL� Other` Slot M1 S length y from 8�to y STATIC WATER LEVEL(all wells) Static water level below land surface 6 It. Date / WELL TEST(production wells) Draw down It. after pumping hr: min.at gpm How measured lG/�p Recovery it. . after_hr. min. ,. o LOG of FORMATIONS . COMMENTS 8 Materials Front To - - lit ,Mel /1 AA 9C.0 �r � Driller lOfi: M44 6t, O Firm OA SGan,.�� cr Uy Address rc,A $uiv cd S y City/Town Supervising Driller Reg.# c7 S J Signature of stipervising registered well driller Please print firmly BOARD OF .HEALTH COPY (vJ Commonwealth of Massachusetts CEEIIVEDExecutive Office of Environmental Affairs 9 1997Department ofEnvironmental Protettio '"°KWilliam F.Weld yGovernor L °1 ry Argeo Paul Celluccl Uvld B.Struhs U.Governor CommlMfomr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION 260 Percival`Dr, W Barnstable Nathan & Sharon Property Address: ► Address of Owner. N o t t k e Date of Inspection: "'�, �� J J' (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: P _ s Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails // Itospeotor's 9ignature:[+rj ; Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: Al SYS PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. Bl SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. to yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. e.' (re sed 1 1/03/95) 1 One Winter Street a Boston,Massachusetts 02106 a FAX(617)556-1049 a Telephone(617)292.5500 Printed on Recycled Paper f r , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddrew 260 Percival Dr, W Barnstable Owner. Nathan & Sharon Nottke Date of Inspection: c I qi ^ Bl SYSTEM CONDITIONALLY PASSES (contin ued) ued) Sewage,backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will page inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(*). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C) FUR ER 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROT ECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT- - The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for ooliform bacteria and volatile organic compounds indicates that the well is tree from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leas than ppm. 3) OTHER (revised 11/03/95) 2 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 260 Percival Dr, W Barnstable Owner. Nathan & Sharon Nottke Date of Inspection: DJ SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the Backup of sewage into facility or system component due to an 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 1/2 day flow. 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 400 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARG SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 lI of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 Ik SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST propertyAddrem 260 Percival Dr, W Barnstable Owner. Nathan & Sharon Nottke Date of Inspeodon: 1 ;L i/_� 7 Check if the following have been done: Pumping information was requested of the owner,occupant, and Board of Health. _None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ZM built plans have been obtained and examined. Note if they are not available with N/A. "The facility or dwelling was inspected for signs of sewage back-up. _ZThe system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. 4ZAll system components, excluding the Soil Absorption System, have been located on the site. _✓The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. _I/The size and location of the Soil Absorption System on the site has been determined based on existing information or - /approximated by non-intrusive methods. y The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddresa: 260 Percival Dr, W Barnstable Owner Nathan & Sharon Nottke Date of Inspection: FLOW CONDITIONS RESIDENTIAL:- Design flow:32 0-gallons Number of bedrooms: Number of current residents: 3 Garbage grinder(yes or no):_&O _ Laundry connected to system(yes or no):y 3 Seasonal use(yes or no):/yv Water meter readings,if available: N/A well water Last date of occupancy: — L1% / COMMERCIAL/INDUSTRIAU Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 6 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes,volume pumped: gallons Reason for pumping: TYPE O 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) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)zle D (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address; 260 Percival Dr, W Barnstable Owner. Nathan & Sharon Nottke Date of Inspection: %—,Z �� Qj SEPTIC TANK:_ (locate on site plan) Depth below grade:�j Material of construction: /Concrete_metal_FRP_other(e:plain) 1 I 00 ) la Dimensions: .-\e 6 Sludge depth: V ' ' , Distance from top of sludge to bottom of outlet tee or baffle:3 Scum thickness: 411 r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) ej /- G TRAP:_ (k►cate on ite plan) Depth belo grade: Material o construction:_concrete_metal_FRP—other(explain) Dimemio Scum ese: Distance top of scum to top of outlet tee or baffle: Distance bottom of scum to bottom of outlet tee or baffle: Comments- (recomme dation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidea of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddrese: 260 Percival Dr, W Barnstable Owner. Nathan & Sharon Nottke Date of Inspection: /44_9 q TIGHT OR HOLDING TANK:_ (kxsete site plan) Depth low grade: Material of constriction:_concrete_metal_FRP_other(e:plain) ' ns: Ca ty: gallons flow: gallons/day level: Cc nts: (oo n of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP C BER_ (locate on plan) Pumps in king order:(yes or no) Comments: (note cc on of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 260 Percival Dr, W Barnstable Owner. Nathan & Sharon Nottke Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): " (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number: leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number: �J Q Comments: (note co 'tion of"soi(,signs of hydraulic failure, level of ponding,condition of vegetation,etc. �cs D �/ 6 , -Z 1 O d g pi 76 6` )e•✓!9d< CESS LS•_ (locate on its plan) Number d configuration: Depth-top of liquid to inlet invert: Depth of lids layer: Depth of scum layer: Dime ' ns of cesspool: Mate ' of construction: Indicatio of groundwater: ow(cesspool must be pumped as part of inspection) Comments: mote condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRIVY: (locate on s' plan) Materials of construction: Dimensions: Depth of so Comments: ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 260 Percival Sr, W/nstab Owner. Nathan & Sharon No Date of Inspeotion: SKIti'!'CH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent referendaIanarkslocate all wells within 100' l< 3 t i yl I � DEPTH TO GROUNDWATER Depth to groundwater: 1, oZ �-feet method of determination or approximation: (revised 11/03/95) 9 �w,nyE 9,��j-Z8- Al t/v v vr,