HomeMy WebLinkAbout0571 WILLOW STREET - Health 5 F1 Willow Street
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Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 12-4-14
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
I
forms tie 1 0
computer,
r,use 1. Inspector: .0 only the tab key ,
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
VQi
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
City/Town State Zip Code
508-420-4534 S14297
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. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
12-4-14
Inspector Signature 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.
M ****This report only,describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or'different conditions of use.
t5ins•3/13 Title 5 Official Inspectio o :Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 12-4-14
every page. Cityrrown 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:
LEACH CHAMBERS WERE OPENED AND DRY AT TIME OF INSPECTION WITH NO SIGNS OF
FAILURE
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
571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 12-4-14
every page. Cityrrown 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)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
Cesspool or ri❑ v is within 50 feet f o a bordering v p privy vegetated wetland or a salt marsh
9 9
t5ins•3113 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
GM ,•°'° 571 WILLOWST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 12-4-14
every pace. 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 DE certified laboratory; for fecak
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
p Y
571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 124-14
every page. Cityfrown 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 nitratemittogen 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 atta;:Ood to thls 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..eontact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
. ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim'Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 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
571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 12-4-14
every page. Cityrrown 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): 5 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
r
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 12-4-14
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 4 H-20
500 GALLON DRYWELLS SURROUNDED WITH STONE
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d WELL
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: 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:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 12-4-14
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: 12-2014
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is WEST BARNSTABLE MA 12-4-14
required for
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2003 PER AS-BUILT
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 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.):
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500
Sludge depth- LIGHT
P
t5ins-3/13 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 571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
informat'on is T
required for WEST BARNSTABLE MA 12-4-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness LIGHT
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? WOODEN POLE
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK LOOKED FINE AT TIME OF INSPECTION
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
El 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 , 571 WILLOW ST
Property Address
KENNEDY
Owner Owners Name
information is required for WEST BARNSTABLE MA 12-4-14
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 12-4-14
every page. Cityrrown 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
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
BOX LEVEL NO LEAKAGE OR SOLID CARRY OVER
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
571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 12-4-14
every 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.):
CHAMBERS WERE DRY AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE OR
SURCHARGE
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 .
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ,a' 571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is requires for WEST BARNSTABLE MA 12-4-14
every 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•3/13 + . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is required for WEST BARNSTABLE MA 12-4-14
every 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
iIt
l
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments
571 WILLOW ST
Property Address
KENNEDY
Owner Owner's Name
information is WEST BARNSTABLE required for NIA 12-4-14
every page. City/Town 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: GREATER THAN 5
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: 12-2014
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:
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
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
yM 571 WILLOW ST
Property Address
KENN EDY
Owner Owner's Name
information is WEST BARNSTABLE MA required for 12-4-14
every page. City/Town 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTABLE
LOCATION 71 WkLL&J ST2i:el- SEWAGE
VILLAGE Wc'?r Najz vS eble ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.la•+ "-Soo;
SEPTIC TANK CAPACITY. 150d Cqu,"s
LEACHING FACII.TTY:(type)LA(Sun far/ 1f-1- DU-eta (size) 'J3�A 4 a.!'
No.OF BEDROOMS!
BUIIAER OR OWNER o 'rVNtw
PERMTTDATE: C MPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any weUs exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
F2or i
o
51' I
a - L 50
0
4)
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=130033&seq=1 12/11/2014
ENVIROTECHLABORATORWS,INC.
MA CERT.NO.:M-MA 063
8Jan Sebastian Dr-Unit#12
Sandwich, AM 02963
508(888-6460) 1-800 339-6460
FAX(908)888-6446
i
CLIENT; Tom Kennedy LOCATION: 571 Willow St
ADDRESS: 575 Willow St W Barnstable MA 02668
IN Barnstable MA 02668 /
COLLECTED BY.. D Pennini/DA Scannell SAMPLE DATE: 8/13/2003
SAMPLE TIME: 4:00
WATER SAMPLE TYPE: New Well DATE RECEIVED: 8/14/2003
LAB I.D. #: 0308329
WELL SPECS.: 125'
RESULTS OF ANALYSIS:
Parameters Units Recommended Results Method Date Analyzed
Limits
Coliform bacteria /100m1 0 0 9222 B 8/14/2003
pH pH units 6.5-8.5 6.46 4500 H+ 8/14/2003
Conductance umhos/cm 500 99 120.1 8/14/2003
Nitrate-N mg/L 10.0 0.04 300.0 8/14/2003
Nitrite-N mg/L 1.00 <0.004 300.0 8/14/2003
Sodium mg/L 20.0 16.4 200.7 8/14/2003
Iron mg/L 0.3 < 0.1 200.7 8/14/2003
Manganese mg/L 0.05 < 0.008 200.7 8/1412003
Volatile Organics ug/L
Chloroform ug/L 4 EPA 524.2 08/14/2003
Toluene ug/L 1,000 0.8 EPA 524.2 08/14/2003
Bromoforyn ug/L * 0.7 EPA 524.2 08/14/2003
COMMENTS: pH is below recommended limit and may have corrosive characteristics.
*Results cannot exceed 80.
WATER MEETS EPA STANDARDS AND IS SUITABLE FOR DRINKING PURPOSES
FOR PARAMETERS TESTED.
ND= None Detected.
<=less than
>=greater than
TNTC=too numerous to count
Date
Ron Id J. Saari
Laboratory Dire or
y
1 .
GROUNDWATER Gro Box 1terAcalyticzl. Ir.c.
ANALYTICAL P.O.Box"°°
228 M21n Street
Buzza-ds Bay. MA 02532
Telephone(508i 759-/,11
August 21, 2003 Fax r508;759-4475
v..vr.3mund:waterana'yt,�-:^r_,r.
Mr. Ron Saari
Envirotech Laboratories, Inc.
8 Jan Sebastian Drive
Unit#12
Sandwich, MA 02563
LABORATORY REPORT
Project: Tom Kennedy/571 Willow St.
Lab I D: 63895
Received: 08-14-03
Dear Ron:
Enclosed are the analytical results for the above referenced project. The project was processed for
Priority turnaround.
This letter authorizes the release of the analytical results, and should be considered a part of this
report. This report contains a sample receipt report detailing the samples received, a project
narrative indicating project changes and non-contormances, a quality control report, and a
statement of our state certifications.
The analytical results contained in this report meet all applicable NELAC standards, except as may
be specifically noted, or described in the project narrative. This report may only be used or
reproduced in its entirety.
I attest under the pains and penalties of perjury that, based upon my inquiry of those individuals
immediately responsible for obtaining the information, the material contained in this report is, to
the best of my knowledge and belief, accurate and complete.
Should you have any questions concerning this report, please do not.hesitate to contact me.
Sincerely,
Jonathan R. Sanford
President
J RS1smd
Enclosures
z
GROUNDWATER
ANALYTICAL
EPA Method 524.2
Volatile Organics by GC/MS
[Field ID: 0308329 Matrix: Aqueous
Project: Tom Kennedy/571 Willow St. Container: 40 mL VOA Vial
Client: Envirotech Laboratories, Inc. Preservation: HCI/C001
Laboratory ID: 63895-01 QC Batch ID: VM7-1276-W
Sampled: 08-13-03 16.00 Instrument ID: MS-7Agilent6990
Received: 08-14-03 15:45 Sample Volume: 25 mL
Analyzed: 08-14-03 21:50 Dilution factor. 1
Analyst: LC Page: 1 of 2
CAS plumber Analyte concentration Notes: I Units = Reportin Ltmrt i
h 75-71-8 Dichlorodifluoromethane i BRL ug/L 0.5
74-87-3 Chloromethane BRL i ug/L 0.5
�75-01-4 ! Vinyl Chloride BRL ug/L i _0 5
74-83-9 Bromomethane BRL _ ug/L 0.5
75-00-3 Chloroethane BRL ug/L 0.5
75-69-4 Trlchlorofluorometha_ne BRL ug/L 0.5 _
75-35-4 1,1-Dichloroethene BRL ug/L 0.5
M 75-09-2 ' ethylene Chloride BRL ! ug/L
156-60-5 trans-1,2-Dichloroethene BRL ug/L 0.5
1634-04-4 Methyl tert-butyl Ether(MTBE) BRL ug/L _ 0.5 -
75-34-3 1,1-Dichloroethane BRL ug/L 0.5
594-20-7 2,2-Dichloropropane BRL ug/L O.5
_156-59-2 ! cis-1,2-Dichloroet:hene BRL i ug/L 0.5
74-97-5 Bromochloromethane BRL i ug/L 0.5
67-66-3 Chloroform 4 ug/L 0.5
71-55-6 1,1,1-Trichloroethane BRL - -� ug/1 0.5
56-23-5 Carbon Tetrachloride BRL ug(L _ 0.5
563-58-6 1,1-Dichlor_opropene BRL ug/L 0.5
71-43-2 Benzene BRL ug/L 0.5
107-06-2 1,2-Dichloroethan_e BRL ug/L _ 0.5
79-01-6 Trichloroethene BRL ug/L 0.5
78 87-5 1,2-Dichloropropane BRL ug/L 0.5
74-95-3 i Dibromomethane BRL ug/L 0.5
75-27-4 Bromodichloromethane BRL ug/L 0.5
10061-01-5 cis-1,3-Dichloropropene BRL ug/L 0.5
108-88-3 Toluene 0.8 ug/L 0.5
10061-02-6 trans-l,3-Dichloropropene BRL ug/L 0.5
79-00-5 1,1,2-Trichloroe_thane BRL ug/L 0.5
.27-18-4 Tetrachloruethene BRL ug/L -0.5
142-28-9 1,3-Dichloropropane BRL ug/L 0.5
124-48-1 Dibromochloromethane. BRL ug/L 0.5 _
_106-93-4 1,2-Dibromoethane BRL ug/L 0.5
106-90-7 Chlorobenzene BRL ug/L 0.5
-630-20-6 1,1,1,2-Tetrachloroethane BRL ug/L 0.5
1:00.41-4 Ethylbenzene BRL ug/L 0.5
10aan-3n0642-3 meta-Xylene and para-Xylene BRL ug/L 0.5
55 47-6 ortho-Xylene BRL ug/L 0.5
100.42-5 Styrene BRL ug/L 0.5
_75-25-2 Bromoform - 0.7 - ug/L 0.5
98-82 8 Isop ropy]ben cene BRL ug/L 0.5
1)8-86-1. Bromobenzene BRL ug/L 0.5
79-34-5 1,1,2,2-Tetrachlorne.thanti. BRL u /�_ 0.5
90-184 1,2,3-Trichloropropane BRL ug/L 0.5
103-65-1 n-Propylbenzene BRL - ug/L 0.5
95-49-8 2-Chlorotoluene BRL ug/L 0.5
108-67-8 1,3,5-Trimethylbenzene BRL ug/L 0.5
Groundwater Analytical, Inc., P.O. Box 1200, 228 Main Street, Buzzards Bay, MA 02532
I
GROUNDWATER
ANALYTICAL
EPA Method 524.2 (Continued)
Volatile Organics by GGMS
Field ID-- 0308329 Matrix: Aqueous
Project: Tom Kennedy/571 Willow SL Container: 40 mL VGA Vial
!Client: Envirotech Laboratories,Inc. Preservation: HCI/Cool
[Laboratory ID: 63895-01 QC Batch I D: VM7-1276-W
Sampled: 08-13-03 16t00 Instrument ID: MS-7 A ilent 6890
P S
Received: 08.14-03 15:45 Sample Volume: 25 mL
Analyzed: 08-14-03 21:50 Dilution Factor: 1
Analyst: LG Page: 2 of 2
CAS Number Analyte Concentration N i its �.
.. .... Notes _ Units �4ig tit i
106-43-4 4-Chlorotoluene BRL ug/L 0.5 _
98-06-6 tort.Butylbenzene BRL —ug/L 0.5
j-63-6 j 1,2,4-Tr r; hylbenzene BKL + ug/LL 0.50.5
135-98-8 sec-Butylbenzene BRL ug/t I 0.5
541-73-1 1,3-Dichlorobenzene BRL ug/L 0.5
9M7-6 4-Isopropyltoluene BRL ug/L 0.5
106-46-7 1,4-Dichlorobenzene BRL ug/L 0.5
95-50-1 1,2-Dichlorobenzene i BRL ug/L 0.5
104-51-B n-Butyl ben zone BRL ug/L 0.5 -
96-12-8 1,2-Dibromo-3-chloropropane BRL ug/L 0.5
120-82-1 1,2,4-Trichlorobenzene BRL i ug/L 0.5
87-68-3 Hexachlorobutadiene BRL ug/L 0.5 _
91-20-3 Naphthalene �— BRL ug/L 0.5
87-61-6 1,2,3-Trichlorobenzene BRL ug/L 0.5
QC.Surrogate Compound . _1 Spiked 7Measuredl Recovery QC Limits
1,2-Dirhlorobenzene-d4 10 10 105 % 70-130 °� ^
4-Bromofluorobenzene 10 10 103 % 70- 130%
Method Reference: Methods for the Determination of organic Compounds in Drinking Watei,Supplement III,US EPA,
EPA-600/R-95/131(1995). Method Revision 4.1.
Report Notaliuits. BRL Indicates concentration,if any,is below reporting limit for analyte. Reporting limit is the lowest concentration that can be
reliably quantified under routine laboratory operating conditions. Reporting limits are adjusted for sample bize and dilution.
Groundwater Analytical, Inc., P.O. Box 1200, 228 Main Street, Buzzards Bay, MA 02532
EAWROTECHLABORATORIES,INC: � � � 0
MA CERT.NO.:M-MA 063
8 jan Sebastian Dr-Unit#12
Sandzn7ch, MA 02963 Q 130
508(888-6460) 1-800 339-6460
FAX(508) 888-6446
CLIENT: Tom Kennedy LOCATION: 571 Willow St
ADDRESS: 575 Willow St W Barnstable MA 02668
W Barnstable MA 02668
COLLECTED BY., D Pennini/DA Scannell SAMPLE DATE. 8/13/2003
SAMPLE TIME: 4:00
WATER SAMPLE TYPE: New Well DATE RECEIVED: 8/14/2003
LAB I.D. #: 0308329
WELL SPECS.: 125'
RESULTS OF ANALYSIS:
Parameters Units Recommended Results Method Date Analyzed
Limits
Coliform bacteria /100ml 0 0 9222 B 8/14/2003
PH i pH units 6.5-8.5 6.46 ; 4500 H+ 8/14/2003
Conductance umhos/cm 500 99 120.1 8/14/2003
Nitrate-N mg/L 10.0 0.04 300.0 8/14/2003
Nitrite-N mg/L 1.00 < 0.004 300.0 8/14/2003
Sodium mg/L 20.0 16.4 200.7 8/14/2003
Iron mg/L 0.3 < 0A 200.7 8/14/2003
Manganese mg/L 0.05 < 0.008 200.7 8/14/2003
Volatile Organics ug/L
Chloroform ug/L 4 EPA 524.2 08/14/2003
Toluene ug/L 1,000 0.8 EPA 524.2 08/14/2003
Bromoform ug/L * 0.7 EPA 524.2 08/14/2003
COMMENTS: pH is below recommended limit and may-gave corrosive characteristics.
*Results cannot exceed 80.
WATER MEETS EPA STANDARDS AND IS SUITABLE FOR DRINKING PURPOSES
FOR PARAMETERS TESTED.
RECEIVED
ND= None Detected. EAUG'2 5 2003 ,
<=less than BNSTr1,BL>=greater than rf f w N J
TNTC=too numerous to count
S Date 6�
Ron Id J. Saari
Laboratory Dire or
GROUNDWATER GroBno Ac21yHCzl. Irc.
P.O.O.Box 12U 11UU
ANALYTICAL Buz Mein Bay.�zzz:ds Bay. MA C2532
Telephone j508j 758-!4�1
FAI X,r508; 75S-2475
August 21, 2003 ,:,•;.�.nuntl,aarp.rana'yt; =:rr.�-.
Mr. Ron Saari
Envirotech Laboratories, Inc.
8 Jan Sebastian Drive
Unit 412
Sandwich, MA 02563
LABORATORY REPORT
-Project: =:Tom Kennedy,571 Willow St.
Lab I D: 63895
Received: 08-14-03
Dear Ron:
Enclosed are the analytical results for the above referenced project. The project was processed for
Priority turnaround.
This letter authorizes the release of the analytical results, and should be considered a part of this
report. This report contains a sample receipt report detailing the samples received, a project
narrative indicating project changes and non-contormances, a quality control report, and a
statement of our state certitications.
The analytical results contained in this report meet all applicable NELAC standards, except as may
be specifically noted, or described in the project narrative. This report may only be used or
reproduced in its entirety.
I attest under the pains and penalties of perjury that, based upon my inquiry of those individuals
immediately responsible for obtaining the intormation, the material contained in this report is,to
the best of my knowledge and beliet, accurate and complete.
Should you have any questions concerning this report, please do not hesitate to contact me.
Sincerely,
U#t.ti
Jonathan R. Sanford
President
J RS/smd
Enclosures
GROUNDWATER
ANALYTICAL
EPA Method 524.2
Volatile Organics by GGMS
Field ID: 0308329 Matrix: Aqueous
Project: Tom Kennedy/571 Willow St. Container: 40 mL VOA Vial
Client: Envirotech Laboratories,Inc. Preservation: HCI/CDnI
Laboratory ID: 63895-01 QC Batch ID: VM7-1276-W
`Sampled: 08-13-03 16.00 Instrument ID: MS-7 Agilent 6890
Received: 08.14-03 15:45 Sample Volume: 25 mt.
Analyzed: 08-14-03 21:50 Dilution Factor. 1
:Analyst: LG Page: t of 2
_
i CAS mbar Analyte Concentra#ion Notes. I Units a�rta,g iimit I
75-71-8 Dichlorodifluoromethane i BRL j ug/L 0.5
74-87-3 Chloromethane BRL i ug/L 0.5
7 Wl-4 ! Vinyl Chloride BRL ug/L i 0
Vi
74-83-9 Bromomethane BRL ug/L 0.5
75-00-3 -Chloroethane BRL ug/L 0.5
_75-69-4 Trichlorofluoromethane BRL ug/L 0.5
.75-3511 1,1-Dichloroethene BRL ug/L 0.5
75-09-2 ' Methylene Chloride BRL ! ug/L 0.5
156 60-5 trans-1,2-Dichloroethe-ne BRL ug/L 0.5
1634-04-4 Methyl te_rt-butyl Ether(MTBE) BRL ug/L _ _ 0.5
75-34-3 1,1-Dichloroethane BRL ug/L 0.5
59420-7 2,2-Dichlorupropane BRL ug/L 0.5
156 59-2 ! cis-1,2-Dichloroethene i BRL ug/L 0.5
74-97-5 Bromochloromethane BRL i up/L 0.5
67-66-3 Chloroform 4 ug/L 0.5
71-55-6 1,1,1-Trichloroethane BRL - -�- _�g/1 - 0.5
56.23-5 Cartwn Tetrachloride BRL ug/L 0.5
563-58-6 1,1-Dichloropropene BRL ug/L 0.5
71-43-2 Benzene BRL ug/L 0.5
107-06-2 1,2-Dichloroethane BRL ug1L 0.5
79-01-6 Trichloroethene BRL ug/L 0.5
7987-5 1,2-Dichloropropane BRL u, .. 0.5
._
_74 95-3 I Dibromomethane BRL ug/L 0.5 _.
75-27-4 Bromodichloromethane BRL ug/L 0.5
10061-01-5 cis-1,3-Dichloropropene BRL ug/L,. 0.5
106-88-3 Toluene ug/L 0.5
10061-02-6 trans-1,3-Dichloropropene BRL ug/L 0.5
79160-5 1,1,2-Trichloroe_thane BRL ug/L 0.5
�. .-..-
127-184. Tetrachloroethene_ BRL ug/L 0.5 _
142-28-9 1,3-Dichloropropane BRL ug/L 0.5
124"8-1 Dibromochloromethane• BRL u8/L. 0.5
10&93-4 1,2-Dibromoethane - BRL ug/L 0.5
106-90-7 Chlorobenzenc BRL ug/L 0.5
63000.6 1,1,1,2-Tetrachloroethane BP.L _ ug/L 0-5
100-41-4 Ethylbenzene _ _ BRL ug/L 0.5
�nazAznn642-3 meta-Xylene and para-Xylene BRL ug/L 0.5
95 47-6 odf lene BRL ug/L 0.5
_.. o-_
100-t2 5 Styrene BRL ug/L 0.5
_..
75:25 2 Bromoform 0.7 .� ug/L 0.5
--
- -
98-82-8 Isopropylbenzene BRL u L 0.5
10E.86-1 Bromobenzene BRL ug/L 0.5
79.34-5 1,1,2,2-TetrachIornethane BRL u L 0.5.
-.. ._
96 18 4 1,2,3-Trichlor013MNJ e BRL ug/L 0.5
103-65-1 n-Propylbenzene BRL ug/L 0.5
95-49-8 2-Chlorotoluene
BRL ug/L 0.5
108-67-8 1,3,5-Trimelhylbenzene BRL ug/L 0.5
Groundwater Analytical, Inc., P.O. Box 1200, 228 Main Street, Buzzards Bay, MA 02532
GROUNDWATER
' ANALYTICAL
EPA Method 524.2 (Continued)
Volatile Organics by GGMS
Field ID: 0308329 Matrix: Aqueous
Project: Tom Kennedy/571 Willow St. Container: 40 mL VOA Vial
Client: Envirotech Laboratories, Inc. Preservation: HCI/Cool
Laboratory ID: 63895-01 QC Batch ID: VM7-1276-W
Sampled: 08-13-03 16:00 Instrument ID: MS-7 Agilent 6890
Received: 08-14-03 15:4S 5ample Volume: 25 mt.
Analyzed: 08-14-03 21:50 Dilution Factor: 1
Page' z°f z
Analpt: LIS
Concentration Notes i units ittprxtiag Limit
W Numl;i,�- Analyte
106434 4-Chlorotoluene BRL ug/L 0.5
9_8 06 6 tern Butylbenzene - BRL —ug/L 0.5
-�..��..
j 95 G3-6 j t,2,4Trimethylbenzene _ BKL _ u�L .— — 0.5
135-98-8 sec-Butylbenzene —� BRL ug/1 I 0.5
541-73-1 ~-1;3-Dichlorobenzene BRL ug/L 0.5
9M7-6 44sopropyltoluene BRL ug/L 0-5
106-4frr7 1,4-Dichlorobenzene BRL u L 0.5
95-50-1 1,2-Dichlorobenzene t BRL ug/L 0.5
104-51-6 n-Butylbenzene BRL ug/L 0.5
9612� 1,2-Dibromo-37Shloropropane BRL ug/L 0.5
120-82-1 1,2,4-Trichlorabenzene BRL ug/L 0.5._
87-68-3 Hexachlorobutadiene BRL ug/L 0.5 _
91-20-3 Naphthalene T- BRL ug/L 0.5
_
7 61 6 1,2,3-Trichlorobenzene --BRL ug/L 0.5
QC.Surrugate Compound Spiked �Mnsuredi Recovery QC Limits
1,2-Dirblorobenzene-d4 10 10 105 % 70-130 %
4-B10mofluorobenzene t0 10 103 % 70- 130%
Method Reference: Methods for the Determination of Organic compounds in Drinking Wetei,Supplement III,US EPA,
EPA-600/R-95/131(1995)- Metfwd Revision 4.1.
Report Nolatiuiu: BRL Indicates concentration,if any,is below reporting limit for analyze. Reporting limit is the lowest concentration that can be
reliably quantified under routine laboratory operating conditions. Reporting limits are adjusted for sample 5iLe and dilution.
Groundwater Analytical, Inc., P.O. Box 1200, 228 Main Street, Buzzards Bay, MA 02532
TOWN OF BARNSTABLE A �
LOCATION 0-t.n+,J S 1'ziel SEWAGE # � 12,
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 1 aM (5
SEPTIC TANK CAPACITY 1506 C4LU-J5
LEACHING FACILrTY: (type)LA C5 a d (;aj h-1 NI-M5(size) 1"3�'A %��L`
NO. OF BEDROOMS
BUILDER OR OWNER D �AwQv
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by — — —
�2vN i
0 48 :
50
4�1
No. � Fee
THE COMMONWEALTH OF MASSACHUSETTS r Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Mi!5pogat *pgtem Construction Permit
Application for a Permit to Construct(Repair( )Upgrade( )Abandon( ) 0 Complete System 0 Individual Components
Location Address or Lot No. 5 7Y WtTO w Owner 1Vame,Address Tel.rJo. 4 2 v_ c�3 3u
Assessor's Map/Parcel K/3D o 3.3 N f j[t S[�Jor- _ O
Installer',,Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
(eneLe;
�Ow
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers(Z) Cafeteria( )
Other Fixtures
Design Flow 1 5-570 gallons per day. Calculated daily flow �_O gallons.
Plan Date 2 l d Number of sheets � Revision Date
Title
Size of Septic Tank // Type of S.A.S.
Description of Soil,wis— "� 4lQ A
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue Bo of Heal
Signed Date
"Application Approved by Date
Application Disapprov or the following reasons
Permit No. 12�3— 2 Date Issued
i C
a t
f
No. 2-coq1 2 Fee
Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,,-MASSACHUSETTS
Zpaplication for Zi5poof bpgtem Con6truction Permit
Application for a Permit�to Construct(Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 5?/ Owner's ,Name,Address and Tel.No. t_f Z U_ U 3 3U
t4jAssessor's Map/Parcel / r
5 (,-/(, d?. akl
Installer's Name,Address,and Tel.No. Designer's Name,Ad ress and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building 1 No.of Persons � Showers(2 Cafeteria( )
Other Fixtures f
Design Flow S5_0 gallons per day. Calculated daily flow gallons.
Plan Date 2 f 8 0 3 Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
s Description of Soil,� l� P
t,�S-I l �
Nature of Repairs or Alterations(Answer,when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Board of Heal .
Signed Date S�
Application Approved by �_ Date 7_ G 7
Application Disapprover the following reasons 41
Permit No. -2 0-0 3 2 Date Issued 2 S
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that th On-site S,pwage Disposal System Constructed(.-j"Repaired( )Upgraded( )
Abandoned( )by !'yi �
at 0-1.i _ n has been constructs in ac ordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. Zco 3' q11 dated 2 5- v 3
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will'function as designed.
Date 11, n Inspectors l� � ----—�
v r �1
No.2CO 3- `! 1 Z
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION .BARNSTABLES MASSACHUSETTS
Migoar *pztem Construction Permit
Permission is hereby granted to Cons"ct(t/)Repair( )Upgrade( )Abandon( )
System located at 57( W i I I ota Sy
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Constru tion in t be completed within three years of the date of this permit
Date: O Approved by
No: ""
p/23' ()37 Fee— - �
---- ------ - --------
BOARD OF HEALTH
TOWN OF BARNSTABLE
0(pp[icat ion.for Well Conotruct ion Permit
Application is Hereby made for a permit to Construct ( V�, Alter ( ), or Repair ( )an individual Well at:
Location — Address Assessors Map and Parcel
6 \/— -- S 7� (.J r 1�i�w — - /` v"ea
Owner Address
Installer — Dn',ller Address
Type of Building
:Dwelling
Other - Type of Building—_—__—____________ No. of Persons-----------------------
Type of Well y it
-- -------- Capacity------------------------------ -
Purpose of Well---- a^`c �c_—__-- �7e!
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 as Certificate Co liance has been issued by the Board of Health.
Signed - C'rtid ----——-- -- —
_R- � _�date
Application Approved By -----——— -- ---
date
Application Disapproved for the following reasons:-----------— —--- -- --- -
------------- -- ------- --------- ---------------------_---
date
Permit No. zo03—o3r7 ---— Issued----� ------ --
date —
BOARD OF HEALTH
TOWN OF BARNSTAB LE
Certificate Of Compliance
THIS IS TO CERTIFY,y►�at the Individual Well Constructed (f Altered ( ) or Repaired/ L C(�0-e �� ---— - -- - ------ ---- --
------------------------------------------------- -
by-----— Installer
at------S >� !,.�l ! eta-, S �� ----------------------- ---------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well,Pr tection
Regulation as described in the application for Well Construction Permit No.W 3-- Dated -j_j(03 ---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---------------------- -- Inspector-------- - --------
/Z�U3=--3 I it - y Fee--- --
No. -- Y
BOARD OF HEALTH �C
TOWN OF BARNSTABLE
Application_*rVell Con0ructionPermit
Application is ereby made for a permit to Construct ( ✓�, Alter ( ), or Repair ( )an individual Well at:
a Location —Address Assessors Map and Parcel
IL�a Tt7M l(t N ry,�P -V_ W
----- Owner — — Address
t
----------------------- ---- - ------------------
Installer — Driller Address
Type of Building-\
n s(�—- - -- - ---------------- "
Dwelling�`� v
Other - Type of Building-------------- - No. of Persons-------------- -----
Type of Well ------- — --- lr Capacity--— - ---——-- —
Purpose of Well--- —
n
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 o Co liance has been issued by the Board of Health.
Signed Dvi_ -- ----- --- date
Application Approved By ---------—— -----
d date
Application Disapproved for the following reasons: -------------_—_ _ ______—_— --_
4
date
Permit No. 2.003-- 03q — Issued---48-1w ----- -- - -
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed (1-f Altered ( ), or Repaired ( )
___ 40 A SG_a r, a //
y Installer
S77- ---------- -----— ,---- --
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pr9tection
Regulation as described in the application for Well Construction Permit No.W 2[3D3'U3� Dated
THEISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL ,
SYSTEM.WILL FUNCTION.SATISFACTORY.
DATE--------- ----- — - --- Inspector-- ----- - -- -- ------- r
1
BOARD OF HEALTH
TOWN OF BARNSTABLE
Yell Con0ruct ion-permit
No.kl2oor3_�b Fee
Permission is hereby granted'D EL G wtnto Construct ( r.Y Alter ( ), r Repair ( ) an Individual Well at:
No. — S '7� w I/a_� S % -- ------ —
street
as shown on the application for a Well Construction Permit No.---� 037 -- __—_--__ Dated— Id 3
,ems
`i O 3 Board of Health
DATE— 1}
TOWN OF BARNSTABLE
LOCATION �/
t`LDu.I S f2tt1 SEWAGE �'t 1.2,
VILLAGE_ ASSESSOR'S MAP & LOT
i INSTALLER'S NAME&PHONE NO. 14 + 4�- l S°'f
SEPTIC TANK CAPACITY 15U� l
� � aL,� 1° "e tju (size) L13�1( � � fl iG o sl
LEACHING FACII.ITY: (type)�T ,
NO.OF BEDROOMS
BUILDER OR OWNER -IA M�±�D
PERMITDATE: C MPLIANCE DATE:
Separation Distance Between the:
Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility (If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
141. 43(�
001 48
Las 150
47
LOCATION ,_ , ' SEWAGE PERMIT NO.20
VILLAGE
( ,? 00,
IWtT All ERIS NAME ' & ADDRESS
B UltDE R OR OWN ER ,,�
DATE PERMIT I S S U E D
• y
DATE COMPLIANCE ISSUED �`ma -77a
mow .
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i
L0,CATLO,N SEWAGE PERMIT NO...
VILLAGE
I-NiSTA4L,LERIS NAM0"& ADDRESS
B .Ufl DE R 4R OWNER
DATE . PERM.IT ISSUED rn"'
DATE COMPLIANCE ISSUED � .-77
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4 1I: 11 • �� .` LAZAMY
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ao 3`MIN. i "JO �. j i �24"MIN �•~ �� , • '� 'ic __ ' tl��� �VV�.SaZ�«.,
a E GA1.. o s`9 a PRECAST OR 4 0, -1
SEPTIC
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SE
EPAGE PIT
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cl et4c4ht31S'Clu'f.�s""t�.
r = - �'c10 M NtMJM c r,~ -^:•:- �.°a - o _,.. .i.._ .+...
FOUIRtATION + _ a o A34AC* FLi
• �,-t-ry{ � .q SCALE i
., C49VATIOa -saE't cw . >r to' pane. RAYQ' 2r��uAm
SCALE, 1 a 4 TEST BY:
C tJg1: cs, t . ..13A' tt.. , ��`' TOWN INSPECTOR, R2AY
•', _ t4tt„r Oft.41+ WA3WC;� "��►J�BACKHOE OPERATOR -----{�-}-
- TEST. MADE ON,
. r
41
.. r '.
,�.+...-. -.�..w.,,.....-.'.:.+-,e.,......w.a+:=�...._-..« �.• .. .�_....--`,...... .... � - .,..,..:-...__ .--.+.-• .� .- .,r...�i..�f�+11-'-';----s:���'"�- .► ''!' - - .a,.'•!� �r.a•.uw�-r=.+ram � ,`•.
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may.. ./i ' .Z.' f • ,, - j y �\, W+!.03
vo
?`E'!' ry '•v . a (�Q �. f `> ~� .f . �r`
APPROVED"BY BOARD OF HEALTH
DATE
v _
OF t
�l ROBERF.
T
- t4 DAYLCO V a
,ELEVAT1 N SCHEDULE
I'. INV. AT fOUNDATI.ON k
2 1NV- INTO SEPTIC TANK i
v {� I +
3. JNV OUT Of SEPTIC TANK = . ��..T VAlkNg. %L14. f-► .4,% w
a. ,cam; INTO `DIs`rRIBU �t -sox _ � _ ��.� `+ . : �#F=��
SCALE,: 1% 1061 JuLr Cj W7
r Cry S Gs • � _ � ,
.±,5:.. INV OUT OF DISTRIBUTION, BOX
6. INV I`NTU SEEPAGE" PIT �("} API: COi� SURVEY CONSU4TAtVTS
Q ROUTE Ila' r 5j
Z borf6M QF PIT _ ' • HYANNIS,MASS.
] A D1#1$19N 60b7CN SURVEY COnSULYANTB, INC—.
•. j
8 BOTTOM OF STONE LAYER
II
�\ o� 7 DATE z✓vG y
a I'J'' � TEST BY:_•� .�-sc y� ,ems' ��
.-c✓s w PROff I LE- NOT TO SCALE s 7f / vz1,
7 LAYER c t ERG R TE�-c Z till
PE.A�TONE
EL= /a S,o FIRST PIPE LDJC�TF1 OVER 3/.I "WAXLE /
0 TOP raWATION COVERS TO WITIIM TO bE SET LEVEL WASHED,; &+F- �!
_ o 0 6" GF FINISFIED GRADE. FOR MIN. 2 v � u
7
TOP a Ly
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2 /0o,7 Namur /oo,3S DISr.
LOCATION MAP /s
�7 ' SEPARATION Z,`e'y 5,1 G1
N /Zy
/6 6" STONE CASE 9U.3 j,/,� L'J /0& 9S o Z
z,5"y c IV
3
_-_ :��.yr�UE' .qL� /•r->�'E/�'Gf�av� ,�J���/�f/�C... Z,Sy� „ 2,S � 3
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9z
5.10 DE5 I CAN DATA
1
1
Z OENERAL NOTES !,
�901 DAILY FLOW: (5)BEDROOMS x1 a OPP=
.5,5-0 ePD
\ /
SEPTIC TANK: SSoC�PD x2CJ0%=1/ooC�PD L CONTRACTOR TO PEE RESPONSf�,LE FOR THE LOGATONOF ALL UTLIT'ES,
USE:/Soc>0ALLON PREGAS,T SEPTG TANK _ .-- ABOVE AND UNDEROROUND,PROR TO ANY EXGAVATI�N OR GONSTRUGTi'>N.
I- LEAGIII NCB FACILITY:
U6E: ..-C4) 57 5"X z s'o o p2yw�c c s, 2- SEPTL SYSTEM TO BE INSTALLED N COMPLIANCE W FH 3b GMR 15.00:TfrL V
y
\ CAPACITY: r 3. THIS PLAN 6 NOT TO BE USED FOR PROPERTY LNE DETERMNATON
SIDEWALL: //o X r- rc O.7 ,/ 2.
BOTTOM: /3 ',t/ yz'X o�7 y = 5�oy o h. ALL DISTURBED AREAS TO pE LOAMED AND SEEDED
TOTAL: 4- 5. GONTRAGTOR TO PROVDE 24 HOUR NOTGE FOR ANY REgURED NSPEGTON�,
B 8 y 20 2,0
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3�
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_ /�l��iyT S�TBAcC" �o moo o. .d o
TE �5EVVAOE FLAI
LoGATIoN: 571 WILLOW ST., WEST f5ARNSTA>LE, M '�.
W I LLOW � ' AA,,
/ PREPARED FOR: TOM KENNEDY
r / i SCALE: DRAWN �>Y:
EVEN W L','i lI L E. _
UM'BZ BF10 AN ``N I , — LION WC'�W
vl P
ssoN � .� -2 B o �4� JOD NUMBER: DATE. SHEET:
Is
Yo�SGFO N A L ENC'\ate 02--OL54 0—I(/
VVELLER & A5�00I TD3
1645 ffALMOUTll RD N SUITE 46, GENTERVILLE, MA OW'Z
V� TEL.: 'S08 775-0735 N FAX: 508 775-0�754
.� PROFESSIONAL ENGINEERS & LAND SURVEYORS
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