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1
YOU WISH TO OPEN A BUSINESS?
For Your information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY RE 4S T ERS YOUR NAIM111E in
town (which you must des by M.G.L. - it does not give you pernnission to operate.) Bus.ness Certificates are available at the Town
Cleric's Office, 1yt FL., 367 Main Street, Hyannis, MIA 02601 (Town Hall)and 200 Main Street Offices at the Licensing counter.
DATE: �/ H
Fill in please:
us APPLICANT'S YOUR NAME: /`//,t
BUSINESS YOUR HOME ADDRESS: E.4 C/(/A .U•�ir/E
t LI�sr A4,4.✓,s r 8cF ,rul Da GG
TELEPHONE # Home Telephone Number:
NAME OF IWEW BUSINESS C'.40� !✓�.✓E 'A60 kq TYPE OF BIJSINES$
IS THIS A HOME OCCUPATION? ,� YES NO
Have;you been given approval.fromthe building<dwrs�on� yES NO
ADDRESS;6F BUSINESS a2_ / irC'�Y-t�.. . Ci✓E ;; " / '' gr� MAPfPARCEL NEIMBER /// 6
When starting a new business there are several thins you must do in`order to-be i n compliance with the 9 Y rules and regulations
P of the Town
of
9
Barnstable. This form-is intended to assist you in obtaining the information you may need.. You MUST GO TO 200 Maas St. -- (corner of
Yarmouth Fed. & Main Street) to male scare you have the appropriate permits and licenses required to legally operate your business
in this town,
1. BUILDING COMMISSIONER'S OFFIC
This individual has n informed f ny permit requirements that pertairMbl8Tsff3,iQbAFAffiWETJJ.HOME OCCUPATION
RULES AND REGULATIONS. FAILURE TO .
Authorized Signature** COMPLY MAY RESULT IN FINES.
COMMENTS:
2. BOARD OF HEALTH
This individual h s en inf r neo
U the unit r uirements that pertain to this type of business.
Authorized 'gnature**
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individ
ual dual has been reformed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
Aj
commonwealth of Massachusetts ,Jo}m Grad
Executive Office of Em Aronmental Affairs D.E.P. 'Title V Septic I ispector
Department of P.O. Box 2119
Environmental Protection T ati) t, 02536
813
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f yo
PART A
CERTIFICATION
271 Percival Dr.W. Barnstable
Property Address: Address of Owner.
Date of Inspection:12/23196 (If different)
Name of Inspector:John Grad Hehman "' 3 199?
Company Name,Address and Telephone Number: /�r���''��,� Aw
",�H _'4
'a
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:
X Passes
Conditionally Passes
_ Needs iFrther Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: 1213o196
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] 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.
Indicate 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 conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 . FAX(61T)556-1049 • Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 271 Percival Dr.W.Barnstable
Owner: Hehman
Date of Inspection:12/23196
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will.pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four 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
obstruction is removed
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 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 PROTECT 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 of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 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 coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in 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
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 271 Percival Dr.W.Barnstable
Owner: Hehman
Date of Inspection:12123f96
D] SYSTEM FAILS(continued)
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).
Numbers 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 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. 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.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
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 II 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 11115195)
3
r-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 271 Percival Dr.W.Barnstable
Owner: Hehman
Date of Inspection:12/23/96
Check if the following have been done:
X Pumping information was requested of the owner,occupant, and Board of Health.
_X__None of the system components have been pumped for at least two weeks and the 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.
n1aAs built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X 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.
X 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.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 271 Percival Dr.W.Barnstable
Owner: Hehman
Date of Inspection:12/23/96
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: nla
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n/a
Design flow:9 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n/a
Last date of occupancy: n/a
OTHER: (Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last two years.
System pumped as part of inspection:(yes or no)No
If yes,volume pumped: U gallons
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions 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 information:
1992
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 271 Percival Dr.W.Barnstabie
Owner: Hehman
Date of Inspection:12123196
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 8"
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'6'H 5'7"W 4'10"
Sludge depth:3'
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 0
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.)
Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: rda
Scum thickness:nfa
Distance from top of scum to top of outlet tee or baffle:nla
Distance from bottom of scum to bottom of outlet tee or baffle: nla
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.)
Na
(revised 11115195)
6
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 271 Percival Dr.W.Barnstable
Owner: Heilman
Date of Inspection:12/23196
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nla
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
n1a
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: Liquid level with bottom of pipe.
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
D-box is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
rVa
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 271 Percival Dr.W.Barnstable
Owner: Hehman
Date of Inspection:12/23/96
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
n1a
Type:
leaching pits,number: 1,000 gallon leach pit
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number, length: n1a
leaching fields, number,dimensions:n1a
overflow cesspool, number:n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit is structurally sound and functioning property,
CESSPOOLS:
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n1a
Materials of construction: n1a
Indication of groundwater: n/a
inflow(cesspool must be pumped as part of inspection)
n1a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
n/a
PRIVY:_
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PrivyComments
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 271 Percival Dr.W.Barnstable
Owner: Hehman
Date of Inspection:12/23196
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
&14
a
Ono
AA 15
A$ �1
a7
� c
�C �9
a D go bd
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
3 Department of Environmental Management/Division of Water Resources
y. WATER WELL""COMPLETION REPORT
WELL LOCATION GEOGRAPHIC DESCRIPTION
Address �
� (feet) (circle) ..
City/Town AA f144
Well owner (road)
Address �-_ ��� N S E W of
(mi.in tenths) (circle)
Board of Health permit: yes no ❑ intersect. IN
(road)
WELL USE WELL DATA
Domestic ❑ Public❑ Industrial ❑ Total well depth �� ft.
Monitoring❑ Other Depth to bedrock . ft.
Water-bearing rock/unconsolidated material:
Method drilled� ��'r�
Datedrilled -3 Description
Water-bearing zones:
CASING �S��C f 1) From To
Type T '—` /x 2) From To
Length, ft. Dia�.LD.) —in.. 3) From To
Length into bedrock ft.
Gravel pack well: dia.
Protective well seal:
Screen: dia.
Grout-[:]. Other Slot#___/_alength from to
PUMP TEST
'Static water level below land surface .a _ft. Date `
Drawdown ft. after pumping Gf hr, min.at gpm
How measured��/,,d,,r,.�'eRecovery ft. after—hr.—min.
0
LOG of FORMATIONS COMMENTS
Materials From To
j i Driller /'
—ate--
Mass. Registration#.
r Firm_ //r/I,GP• f /.�f
Address -
e City/Town
V,
Sr nature o!supervising regrste`redwell driller
P/ease print firmly
BOARD OF, HEALTH COPY
�Z 7/V q/ C�WN OF BARNSTABLE
LGCATI /SEWAGE #
`VILLAGE la e 5-7- A?,t�[_ ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. wRG'/'�1,����.�o
SEPTIC TANK CAPACITY
LEACHING FACILITYAtype) «I4✓,,e (size)
NO. OF BEDROOMS-_? PRIVATE WELL OR PUBLIC WATER u ,C
j/
BUILDER OR OWNER A d 2 4le�iy� f'
DATE PERMIT ISSUED: 41-02
DATE COMPLIANCE ISSUED:/,-F16/'
6
VARIANCE GRANTED: Yes No
t t
® .4 ! /S '
4
4-. , i� ''�J d- ._. t`a ...���G��✓ �/ _ _ .� yr.
THE COMMONWEALTH OF MASSAA SETTS
BOAR® OF HEALTH
..T
.._. .O()
OF .................._
Apfiration for Biopooal Works Tonotrurtion Famit
lication is hereby made for a Permit to Construct ,�or Repair an Individual Sewage Disposal
� PP Y ( "'J P ( ) g P
ys t: _ t
�� �2
- ..._.. ...... - ..... ....................
Location- -ddress or Lot No.
Owner Address
W
Address
Q Type of Building V/14Il A e Size Lot.........4. Sq. feet
Dwelling :No. of Bedrooms................. ...••__-•-_-..•____-____Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons---------------•____-___--__ Showers — Cafeteria
Q' Other fixtures _._
WDesign Flow.....................�.1... -__gallons per person per day. Total daily flow..........................., .___0..gallons.
9 Septic Tank—Liquid capacity gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No. ........... ....... Width_ia.................... Total Length.......... ._...... Total leaching area....................sq. ft.
(Seepage Pit No.----_-_---. ....._. iameter........A .... Depth below inlet...... ...... Total leaching area... 14.'.sq. ft.
Z Other Distribution box ( Dosingtank ( ) pc, (�
'~ Percolation Test Results Performed .- _._.___ .... .......... . .�. Date......... "�_�......
Test Pit No. I.....`Z.— minutes per inch Depth of Test Pit....... ,,._ Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•---••--------------••-•-• -- ----- .................................................................................
O Description of Soil '.1' ------...."U....... 5�7-1-�`_a---------------------------------------------------------•---
U f�
- ..... �. 1 L .
W fZ It ,ate :c
VNature 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.
1 .............. ..--------...... ......
Application Approved'By - --- ---- ---- ......... .... ... ............... .. 14VI�L3
......-... ---------------- ----------
Application Disapproved for the following re sons- ---------------------------------------------------------------- -------- - ------ ------------------------------ -------
.............--------............................
........ .: .........:.. ------------------------.... ....... ---
-- --- ----------
l Da�e
Permit No. ......... Issued ..... 7 -/
Dare- --------' ... ..............
No..........•-•--_....... Fim........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................OF..... Fkl� h�'',i.. �,(te a.......
llp iration for Uigpnsal Workii Tonstrurtion ranfit
Application is hereby made for a Permit to Construct ( �)�r Repair ( ) an Individual Sewage Disposal
System at: 1
Cad?_ € . .... �(... ..�7`
Location-Address or Lot No.
.................................................................................................. ..........--.....................................................................................
Owner Address
W
� ! n llej Address
d Type of Building V / i �?� Expansion Attic Size Lot.-Garbaf e Grinderq feet
V DwellingNo. of Bedrooms__:.::_:•----- No. of persons............................ Showers — Cafeteria 9a4 Other—Type of Building p ( ) ( )
Other fixtures„
- -•-•---...-•--------------------------------- ---------------•--------------••--------------
W
Design Flow.....................` '. ...............gallons per person per day. Total daily flow............................
WSeptic Tank—Liquid capacity.4 gallons Length................ Width................ Diameter_------------- Depth................
x Disposal Trench—No...................... Width_;...---.....:------ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------------_-.-_ Diameter.-_- .... Depth below inlet....... -2.... Total leaching area...V..l...sq. ft.
Z Other Distribution box ( t)* Dosing tank ( 5�
Percolation Test Results Performed by --.:.:...___._:_,.....:...........................
. Ce Date••-- !+ .. �S
Test Pit No. 1....""7__,-minutes per inch Depth of Test Pit-------)-'?_.-_... Depth to ground water------------------------
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a .....................................=-----•--------------•--......------•--...................------------..................--
xW T' �.1L �c.�u�� t C. .0Description of Soil------------------------0.-=t..s........------ - ----- - _
i_ ... .... -----
-----7--- ---------------------------•----------------
Tf
c a U Nature of Repairs or Alterations—Answer when applicable...................................
I
..............................................................-........................................................................................................................................
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.
c l0 C ^_ -'------- -- ---y ... ... ............................................... ... ....... . .. ..........
' r ...Dace f /��
Application Approved B ' 'Date,/
�i ...................`...; .. . �I.
J t / I 'Date
Application Disapproved for the following reasons- ------------------------ -------------------------------------------------- - -- -------------------------------- -------
r. .ram+ / l I -
.............................................................-....:............:^.............................................................................................-.......................--..... ----...............................----
•-� / Date
Permit No. ._ .�..`- .... .... Issued ..............I.III(t
f ( Date/
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH_
)� ! t t
Ouvrtifirate of Qlantyliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
1,n taller
----- ----
has been installed in accordance with the provisions of TITLE 5,,of The State_Environmental Code as described in
the application for Disposal Works Construction Permit No. dated ..--..-----.. ........................... ......-------...-----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUWAS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ `l '�..��...6 Inspector .. .....� s
THE COMMONWEALTH OF` MASSACHUSETTS
BOARDnOF HEALTH
No. .....:............ ..................... . ... FEE........................
Permission is hereby granted..... ��.... r am- ...................................................................
to Construct or Repairj() -) an Individual Sewage4D3sposal System
I .
at No •----------•-•----------..------•------------•-----•-------------•..................
Street .'
as shown on the application for Disposal Works Construction Permit ---..---..-----
Dated..........................................
---
g ---. ------
DATE--------•-U.....O��' t-'C�............. � Board of Health
r
FORM 1255 HOBBS & WARREN. INC..-`PUBLISHERS
NO. _°�- ------- �. Fee-- =- -
BOARD OF HEALTH
TOWN OF BARNSTABLE
z.pplitationArIverf Construction'Vermit
Application is hereby ade for a permit to C nstruct ( ), Alter ( ), or Repair lan individual Well at:
Location — Address"` Assessors Map and Parcel
v �
------------Z_ r16 40 1l s---- -----
)�(Owner / l (/
)
Installer Driller Address
tJ I
� N - 3 F YL�Q7 13
- - - ---------------------------
Address
Type of Building
Dwelling--- --------------------------------------------
Other - Type of Building --------------- No. of Persons-------------------------------------- ---
Typeof Well--_- -` ---------------------------------------------- Capacity-----------------------------------------------------------------__—_—
Purposeof 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— -
�7date
Application Approved By----- ------- -------------------
date
Application Disapproved for the following reasons:---------------------___________________________-_-_____-________-___:_____________._______
-___—_ - --- -- - -- ---------------------------------------------
date
Permit No. —`J�-l—t -----____ Issued
date �—
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
e Individual Well Constructed (. ), Altered ( ), or Reps aired
THIS IS ER That t ( )
-------------- r���� ! � 4 - ------
Installer
at
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE --- - --- —------------------ - - -- Inspector------------------------------------------------ ------
.-K►r
No.----`-'--`-"---- �, Fee-----------____G--- -
BOARD OF HEALTH
' TOWN 'OF BAR-NSTABLE
Zippfitation-for lVerr Cootruct ion 3permit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( fan �dividual/
Well at:
Location — Address Assessors Map and Parcel
Owner Address
'�/q/Z/ �G Q 1 t �t^t n — J
-- -- - ---------------------------------------------------- -------------------- ----
Installer — Driller Address
Type of Building PR ,
Dwelling— -- - — - -- ----------
Other - Type of Building ----------- No. of Persons------------------------------------------------------
Type of Well- -- --'1__--—- -- - - -- 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 ----I�WwLe-----------
date
Application Approved B --�r!/.1-� `
A
PP PP Y -' date
Application Disapproved for the following reasons:.-----
--------------------------------------------------------------------------------------------------------------------------------
--------------------
date
Permit No.--4/-'' -`- -- --- Issued - - - r -- -----
�. date
BOARD OF HEALTH
TOWN OF BARNSTABLE
.Certificate Of Compliances
THIS IS�TOERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
by o� ��- % -��- ------- --
Installer
at------ 1--�' _ -J F✓��'_i jej_t- W-`----&-_t!t .___/i I 1 F_--------------------------
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
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------ -------- Inspector--------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Very Congtruction3permit
No. --------------------- Fee------------
! � - -----------------------------------------------------------
Permission is hereby granted- -` - / v--
to Construct V), Alter ( ), or Repair ( i,)-an Indi idual Well a
No. -- - -- - -- ----- :-- 'c2 �!` L-_f��C_ - / _-------
Street
as shown .on the application for a Well Construction Permit
No.- - /--'��' Dated - - �-- —= ---- --
Board of Health
DATE - -----------------------------------
IV
'( AZrAO 114C-
------------
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PETER �o
ULLIVAN
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�► : No. 29733. 'oAFsFc�srEaE
`� S70NAL ENS'\
Log Number. Bottle # BC4A Date: 7/1/93 71
. t
OF BAl�,4
�� sa BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT
Z SUPERIOR COURT HOUSE
BARNSTABLE, MASSACHUSETTS 02630
J
° 55 °. DRINKING WATER LABORATORY ANALYSIS PHONE:362-2511
Ext. 337
Client: Tartan Inc. Collector: Georcte Heufelder
Mailing Address: p„ 0. BOX 1198 Affiliation: County
West Chatham, MA, 0P869 Time Date of ,
Collection: 6/28/93 3:00 p.m.
Telephone: Type of Supply:
Sample Location: Int 16 _ Ppm-i-xv;1 Well Depth:
Barnstable. IAA. Date of Analysis: 6/29/93 9:00 a.m.
PARAMETER SAMPLE RESULT RECOMMENDED LIMITS
Total Coliform Bacteria/100 ml 0 0
H 6.2
Conductivity (micromhos/cm) 99 500.0
Iron m) 0.1 0.3
Nitrate-Nitro en ( m) 0.8 10.0
Sodium m) 9 20.0
Copper (ppm) 0.1 1.3
I . XXOX 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.
B. The 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
D. 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
Laboratory Director
1 /7/85
Explanation of Test Results
Total Coliform Bacteria
Coliform bacteria are an indicator of the sanitary quality of a water supply.. Water supplies ma.,Y become
contaminated from malfunctioning septic systems, cesspools and surface runoff. A total coliform count of zero
indicates that your water supply is safe and approved for human consumption. A total coliform count of greater than
zero,is most often the result of accidental contamination of the sample bottle through improper sampling methods.
For this reason, it would be advisable to retest any well water that is not approved.
pH
pH is the measure of acidity oralkalinityof the water. On the pH scale, the number 7 is neutral. less than 7 is acidic
and more than 7 is alkaline. The pH of water on Cape Cod tends to be acidic in the range of 5.0 to 6.5.
Conductivity
Conductivity is a measure of the dissolved salts in solution. Amounts in excess of 500 micromhos/cm are generally
considered unacceptable and may have a laxative effect upon users.
Iron
The presence of iron in water in concentration of .3 ppm or greater may: give the water a bittersweet astringent
taste, cause an unpleasant odor, often gives the water a brownish color and cause staining of laundry and porcelain.
The average concentration of iron in Cape Cod's water is .2 - .6 ppm. Although the presence of iron in water ma
cause the problems listed above, it is not considered deleterious to health. Iron may be removed by use of an iron
removal system.
Nitrate-nitrogen
The Massachusetts Drinking Water Regulations have set a maximum contaminant level for nitrates at 10 ppm.
Excessive concentrations may cause methemoglobinemia (an infant disease) and have been suggested to form
potentially carcinogenic nitrosamines. Contamination sources include fertilizers, cesspools and industrial wastes.
Copper
Due to the acidic nature of the water on Cape Cod, copper tends to leach from pipes. This normally does not
present a health hazard; however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a
bluish-green stain on porcelain fixtures.
Sodium
A concentration of sodium over 20 ppm is only of concern to people who are on a low sodium diet. If the water
supply has more than 20 ppm sodium, it is up to the people who are on such a diet to find another source of drinking
water or contact their doctor to determine if consuming the water is advisable. Concentrations exceeding 50 ppm
indicate that there may be ocean water or road salt runoff water getting into the well.
BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT LABORATORY REPORT
VOLATILE ORGANIC CHEMICAL ANALYTICAL RESULTS
Client: TARTAN INC Collection Date: 06/29/93
Mailing Address:P 0 BOX 1198 Date of Analysis : 06/29/93
WEST CHATHAM MA 02669 Type of Supply: WELL
Well Depth (FT) : Not Given
Telephone:
Sample Location: PERCIVAL LANE LAT. (DDMMSS) : Not Given
BARNSTABLE - LONG. (DDMMSS) : Not Given
Collector: G HEUFELDER Map/Parcel : LOT 16
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 3.7 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