HomeMy WebLinkAbout0024 BEECHWOOD ROAD - Health 24 Beachwood Road
Centerville ti
A 252 177
I
SMEAD
No.H163OR
UPC 10259
smead.com • Made in USA
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DATE 12/16/06
PROPERTY ADDRESS 24 Beechwood Road
Centerville
MA 02632
On the above date, the septic system at the address above was
Inspected.
This system consists f the fpllowing:
I, i ' i,600 dal r) `
D t5�rt b U eon X
Based on inspection, I certify the following c nditions:
i 1 51-5 c' vale Ftv� �c �j� ' �-7$) cod-e-
y 5 beam L5 -P cc P- wo r(c i nJ o
0� kv_ re r-ewe-n+
Co. Less i ' C�5 t)r-ti cj �cxnR- r
_: CD
7�n� C"D rj
°� SIGNATURE _
�.I F
W# w -r
Name: Robert A. Paolini E31
Company: Joseph P. Macomber & Son Inc . 3
_ ED
Address: P. 0. Box 66 co
Centerville. Mass 02632
Phone: 508-775-3338 or 508-775-6412
JOSEPH P. MACOMBER & SON,. INC.
Tanks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
r
COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM,.NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART-A
CERTIFICATION
Property Address: .. 24 Beechwood Road
Centerville MA 02632
Owner's Name: Linda Esterle
Owner's Address: Same
Date of Inspection: 1 2 f 1 h/0 6
Name of Inspector: (please print) Robert A Pao.lini
Company Name: �, P..8acomf.ca .S:o.n Inc.
Mailing Address:
a� Cen eay.c e, Nazz..02632
Telephone Number: 5 0 8-7 7 5-3 3 3 8
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 the inspection.The inspection was performed based on my
training and experience in;the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant tSection.15:340 of Title 5(3
a 10 CMR M000). .The system:
YX Passes _
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ils
Inspector's Signature: I 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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of J 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM !`
PART A
CERTIFICATION (continued)
Property Address: 24 Beechwood Road
Centerville MA 02632
owner: Linda Esterle
Date of Inspection: 1 2/1 6/0 6
Inspection Summary: Check A,13,C,D or.E/AIMAY 'complete afl of Section.D
A. System Passes:
I have not found any information which indioateslhat any of the failure criteria described;in 3,10 CMR
15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
1� 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.
Answer yes,no or not-determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
i� 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.
ND explain:
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 inspectionif(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
2_
Page 3,of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 24 Beechwood Road
Centerville MA
Owner: Linda Esterle
Date of Inspection: 12 1670 6
C. Further Evaluation is Required by the Board of Health:
Conditions exist which,require further evaluation by the Board of Health in order to de_termine 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(l)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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:
YW 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 5Q feet or more fron]a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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:
3
Page 4 of I 1
OFFICIAL-INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 24 Beechwood Road
Centerville MA 02632
Owner: Linda Esterle
Date of Inspection: 1 2/1 6/0 6
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the.followingfor all inspections:
Yes Np
_ ✓ Backup of sewage into facility pr.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'h.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 SAS,cesspool or privy is below high ground water elevation.
_ -7 .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.
An portion of a cesspool or privy is within.50 feet of a private water supply well.
_ Y
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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from..that facility 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 forT.]
Qb (Yes/No)The system fails.I have determined that,one ormore.of.the above failure-criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner.shoutd contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a.facility with a design flow of 101000 gpd to 15,000
gpd. .
You must indicate either"yes"or"no"to,each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 1I 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.
4
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART B
CHECKLIST,
Property Address: 24 Be,echwood Road
Centerville MA 02632
Owner: Linda Esterle
Date of Inspection: 1 2/1 6/0 6
Check if the following have been done.You must indicate"yes"or"no"'as t.o 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:
Yes no
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(3)(b)]
5
Page 6 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.:SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 24 Beechwood Road
Centerville MA 02632
Owner: Linda Esterle
Date of Inspection: 12/1 h/o 6
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms):3 K((S'" .33�D 5 I°�
Number of current residents' ' -n)6 e,
Does residence have a garbage grinder(yes or no): f=5
Is laundry on a separate sewage system(yes or no): I lo`[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): c�C%75-- )40)0 00 _ 1
Water meter readings, if available(last 2 years usage(gpd)): AOQ to —&.DOQ 01 •1 .
Sump pump(yes or no):fti0
Last date of occupancy:
COMMERCIALdNOUSTWAL
Type of establishment: VCI\
Design flow(l' don 310 CMR 15.203): gpd
Basis of design,'flow(seats/persons/sgft,etc.):.
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water-meter readings,if available:
Last date of occupancy/use: .
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or 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)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): M
6
Page 7 of 11 y
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM"INFORMATION(continued)
Property Address: 24 Beechwood Road
Centerville MA 02632
Owner: Linda. Esterle-
Date of Inspection: 1 2/1 6/0 6
BUILDING SEWER(locate on site plan)
J
Depth below grade:
Materials of construction:_cast iron Y 40 PVC_other(explain):
Distance from private water supply well or suction line: 113
Comen (on condition of joints, entin evide_nce of leakage, c.)
m
SEPTIC TANK:_(locate on site plan)
Depth below grade: /
Material of.construction:`�concrete_metal_fiberglass polyethylene
other(explain)
I_f iank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_.(attach.a copy of
certificate) �� ,. 11
Dimensions: ®�ol $
Sludge depth: `xsox(C,L
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: V�p n' .
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: V 51J dJ ctlm1 f 1eet,9'U�—
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet inv evidence of-leakage,et
�� . .):
oe �
GREASE TRAP:Loocate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of le age;etc.):
VLO 2S�.YL.
7
Page 8,of 11
OFFICIAL INSPECTION FORM_—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION FORM %—
PART C
SYSTEM INFORMATION(continued)
Property Address: 24 Beechwood Road
ntPrvi11e MA 02632
Owner: T.i n8;; PSI-erl®
Date of Inspection: 119,41614()6
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(explaih):• .
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes.or no):
Date of last pumping:
Comments co dition of al float sw' ches,a c.):
4
DISTRIBUTION BOX: (if present must be opened)(locate on site plan) .
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leaks a into or out of box,etc. :
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments note condition of pTpha �ber,codition of pumps any appurtenances,etc.):
8
Page,9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 24 Beechwood Road
Centerville MA 02632
Owner: Linda Esterle_
Date of Inspection: 1 2/1 6/0 6
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not lQcate4 ex lain why:
kpe
leaching pits,number: f
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
�. v sw Pit
'm
CESSPOOLS:f u�l (cesspool must be pumped as part of mspection)(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`or no):
Comments(note condition of soil,signs of JWdraulic failure,level of ponding,condition of vegetation,etc.):
C44 1 Vint re 1n k
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Co ents(note cond'tio f soil,st s f hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 1 Q of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE-DISPOSAL SYSTEM INSPECTION FORM i
PART C
SYSTEM INFORMATION(continued)
Property Address: 24 Beechwood Road
Centerville MA 02632
Owner: Linda Ester
Date of Inspection:_1 2 11 ti/a 6
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at Ieast two permanent refffe-iice landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
• — _ __ Ala,, _
10
Page I l of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address: .24 Beechwood Road
Centerville MA 02632
Owner: Linda Esterle
Date of Inspection: 1 2/1 6/0 6
SITE EXAM .
Slope
Surface water
Check cellar -
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high groundwater elevation:
•N U Obtained from system design plans on record-If checked,date of design plan reviewed:
u e.3Observed site(abutting property/observation hole within 150 feet of SAS)
Ve,3 Checked with local Board of Health-explain:rL.c D u ft r ri li d
no Checked with local excavators,installers-(attach documentation)
Accessed USGS datffbase-explainA-t;6/2 r down.,gaanztagPe.,ma.,uh
/�. You must describe how you established the high ground water elevation:
Used • CaRe Cod Commizzon Oatea Taa.Pe Coritoua,6 And %u��ce lJatea Su��2y
Oeii head pzoteci-io-n aaeaz map o SeRt 1995
Uatea aezouzces o,E,�'ice cage cod comm.i-6.40n ,
Top of Ground
Leaching 11]
Pit {eet
5
Groundwater: Feet Below Bottom.- f Pit High Groundwater'Adjustment 1.8 ft per Frimpter Method •l A�wS
Therefore,the vertical separation distance between the bottom /
of the leaching pit and the adjusted groundwater table is
feet.
11
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'TOWN OF BARNSTABL E BOARD QF I1RAW11
.SUBSURFACR 89WAUR DISPOSAL SYSTFM INSPRCTON FORM - PART D. CERTIFICATION
»••sr, 4 logo/Ilong TIrAM " .
-TYPO 01 PRINT MANLY-
PROPERTY rNSPRCTEJ2
STRUT ADDLES$ 24 Beechwood Road Centerville 02632'
ASSESSORS MAP, BLWK' AND 'PARCEL '
OWNER's NAME Z,inda Esltezl-e
PART*.*D 0SRrX_TXC!=K0N
NAME -OF INSPECTOR Robert: A:Taoli: i
COMPANY NAME . • :r•
COMPANY ADD.R98S �f:•�'�:�ox- 66'�C�r� .�rz�il�.� M� °Q 32-006�
Str• k' :. 7okn'•or ty.. state L A
COMPANY TELEPHONE ( 5 pg. ): 7.5 .- 3338 FAX (' 508'r90
CERT•I•FICATION. STATEMENT
I certify that I beivai persorial,17 .Ins-pected ..the &swage 'digPopil. system at
klecoinmendations
his add.ress -and that- .W);e' information reported ,is true,. aoctira•te•, grid
omplete aq of the time .ovf'�inspictlon.�• The inOPeotian was performed and any
'
regard.ing .upgrade•; .ma•inte.nanee,'. abd rep4.1r ,afie• eongis'tent
Witt, my trainip,g and exPgrience in th$ Ppoper function. and maintenance of on-
site sewage disposal. sy$te,ne
Check one;
.ZSystenf -PASD <
The, inspection which J. have .•oondugted has .,n•at found any information .
which indicates' that ,the system' Vials to ' adeua•te,ly„ protect .publiq
health or tfle envi.ro pment as defined ill .310 CMR. 15 30.3•�
� •Any faiiu•re
criteria o6t ••evalun.ied' are as stated in the FAILVItR CRI't'1rRSA •section of
this, form.
.� System FAILED* 1 '
The inRpec•tion whiclr I Ita'vq co�fic�Mited has found that •the gyatem fails to
rrotec.t theublia 1'iea].ttl end thq engronmen•t ' in agoo'rd•ano�e with Title
61 310 CMR 16 408 , and as • speeifioali,y noted -on .PNkT••C ..» FAILURE
CRITERIA of this In i,on .form
Inspector 6ignature ` • ; U& $ �� ��
ne' copy of this certl f ioe;t•i:ah inust •6e l?'rovided :to the QW >rR.� hq BU'fER'
where appli:oablo) and t•ht UPARD OV HEAL-tit
* Xf the inspection FAX 'tho .6wne1,',ox gpgrator s:heil,� . upg.y.,a e�the dyetem.
within obe year of the dat-e of the inapection, unless, al;'loa,ed Qr' regiti.,red .
n h.h—wise. a8 Provided ifl �3;14 CMR 16 ,306 ,• ;
No.... FE$...11.40 .
THE COMMONWEALTH OF MASSAC SETTS
. BOAR OF !-1 EA T
.................OF............................................. ...........................................
,� r rliraaUon for Uispaa al Vvrks - nnilrurtinn ramit
Application is hereby made for a Permit to Construct ( ' ) or X-C air (i ) an Individual Sewage Disposal
System at:
L ation-Addres ` or Lot No.
Qr - .- - ------ ---------:- ------------........---------------------------•----
n / Address
W -
...................
a Installer Address
dType of Building Size Lot...........................Sq. feet
Dwelling—No. of Bedrooms.__...3..................................Expansion Attic ( ) Garbage Grinder ( y,
-.0ther—Type of Building No. of `ersons............................ Showers — Cafeteria
Q' Other fixtures ................................................
W Design Flow.... j�.................................gallons per person per day. Total daily flow.....Z_3_Q--------------------------gallons.
WSeptic Tank—Liquid capacityl5Qd_gallons Length________________ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......A1M.... Diameter.......120-------- Depth'below inlet.........Aa...... Total leaching area....! ,'10...sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by........PV ' ................................. Date.....ti.2al.e ...............
Test Pit No. 1....e--5.1—minutes per inch Depth of Test Pit--3- Depth to ground water..'-_.���. -.
fs, Test Pit No. 2................minutes per inch Depth of Test Pit Z.._...._._. Depth to ground water........................
J ...................�.
O Description of Soil - �------••••----•---•••------` ----•-----------------------------------
U --••-••••----•-•-•••----••---•--••---•-•----•••••------••--•---•-•�-•-••---•-••-------•-•--•-�-�=`�--`'�-----------------------------`--------------------------------
W ----------------------------------------------------------------(•••-••---------•-•-•-- --------------------- - . .......................... ..
UNature of Repairs or Alterations—Answer when pplicable....................................
-•--------------------------------------------- ---------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ITIE 5 of the.State Sanitary Code— The undersigned further agrees not t *1ace system in
operation until a Certificate of Compliance has been issued by t e o r oft lth.
Si ned•••-•l�� �............................✓ ae
Application Approved BY---- ----- --- ✓-•�'--�-- -- ------------------•--------- ---------------------
--•-'�-`-.............
�
� Date
Application Disapproved for the following reasons:...............................:..... �
•-•--------•-------------•--•-----•---••---•-------•----•--------•-•-•------------•'-----•-•-----------------•---•---------•----------•-----•--•-------•----... ------..._.
Date .--
PermitNo......................................................... Issued.......................................................
Date
�j
No.. ... `!....T
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................... ..................OF.............. ........................
Appliration for Disposal Works Tonitrur#ion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................_........_...................................................................... .....-•-•--------•-•---•-•-•-•-•................--•--••-•----•--•-••. ....._..._..-
Location-Address or Lot No.
......................».......................................................................... ..........--......................................................................................
W Owner Address
Installer Address
UType of Building Size Lot--------------------------_Sq. feet
�-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a` 4 Other—T e of Building No. of persons............................ Showers
YP g --------•------------------- P ( ) — Cafeteria ( )
04 Other fixtures -----------•-------------------------------------------------------•--•-----•••-•----------•-•-••••--•---.......---•-----......------..........------
WDesign Flow............................................gallons per person per day. Total daily flow..................._.................._.....gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter_--_--__--_-_- Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter...................... Depth below inlet.................... Total leaching area....-.. ........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
�-' Percolation Test Results Performed by------.` ='- Date
Test Pit No. 1__.:!_Z-..minutes per inch Depth of Test Pit..I..`...... Depth to ground water.----- -------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 •-•-------••-----•-•-----------•-------•-------•---••-•.....-----•........--•---•-•.......--•.....•.---•.....----•...............••....._...-------•---.--•--
0 Description of Soil........................................................................................................................................................................
W
U ----••--•.......................•---•••-•----•-•---.......--•--.........------•-----...........-----•......•••------•--•-•---•--........---•-....._..••••--....--•-......---•-----••----•-•---------•--
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------...-•-•-•---•-
U Nature 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 TIT!c E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boards of health.
-_
Signed.......`.........!••
--•-----------------------•--•--•-......-----•--•---..----
/'.—._7 _y. / � Date
Application Approved By.............=-' _....._".:.._.: ��.._ ......-----•-••--------•.............. ----------I...................".-.-.-.-.-.-.-.-..-.--
.
Date
Application Disapproved for the following reasons-----------------------••----..........--•-------------------•------------------•----------------.....-----......
--------------------•----------------•--•---------------------•---•--------------.....-----------•------•---•----•-------•----•-----•---•----------•-••••----------••-•-------•-----•••---•-•-•-•-----•-
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS �!
BOARD OF HEALTH f
......./....^........................OF.............:- ?....:.......:........:......................................
�rdifiratr of ft�ont�rli nrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed �or Repaired.(, )
by-----------•-------------------------------------------------------------------------------------------------------------------------------------------•---•-.-------•-.----•----/-...-......../^ Installer .......................................
has been installed in accordance with the provisions of TITLE' 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..... ............... dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................�aZ4&---•----_---•--•------------- Inspector...... '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- ^ ,........OF...........:
No� '2 . r .._.�....�..`......_....../.. . w FEE. '.
C
Disposal Works Tonotrnrfion rrnti#
Permissionis hereby granted..............................................................................................................................................
to Construct Repair ( ) an Individual Sewage Disposal System
at No............... i - s > _ E / .r C_ i i Ile-
Street
as shown on the application for Disposal Works Construction Permit No......................Dated..........................................
DATE. 111310 Boardaof Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
0 j
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OF MAss9cti
or JOHN �
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.p No.29874ILI
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LEGEND
EXISTING SPOT ELEVATION Ox0 r4 . ,C la, CERTIFIED PLOT -PLAN
EXISTING CONTOUR ---
FINISHED SPOT ELEVATION
FINISHED CONTOUR 0
sr1 � IN
APPROVED BOARD OF HEALTH I
DATE AGENT '�> �;` 4 SCALE= �s 30 DATE,G / Fq-r /
LOREDGE ENGINEER " CO. 'NoCLIENT s °'�-�c I- CERTIFY THAT THE PROPOSED
EGISTERE REGISTERED JOB N0. G 4� BUILDING SHOWN ON THIS PLAN
CIVIL LAND R pQ CONFORMS TO THE ZONING LAWS
ENGINEER SURVEYOR DR.BY OF BARNSTA E, 33.
7I2 MAIN ST. CH. BY: ,f A
HYANNIS,- MASS.
SHEET OF DATE ( R LAND SURVEYOR
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[Y TE /F E�TNER-.THE SEPTIC TANK ORS
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/N�.ET D/ST/q/Bt?lON Box FT SECTION OF GROUNo 4TER THOLE
,odTLtTo�sTRi®uT�oN BOX FT SEWAGE 6�15P"A L .SV.ST'EM
/N[.ET LEACMIwG P'/T 4I:0-Fr -rAQZ1l-AT/ON
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TOTAL EST//M4rwo FLOJV 3 0G.4L.1A•4Y � 60/C TEST 0/ SO/L TES77402
A/UMBFiP G1F LFACXfNG P/TS_1 ELc'Y. 9�l EL1•Yp 0.4TE OF SO/L TEST
S/OE LEAGHIN6 PER P/T Si$t PT. RZSI/LTS Jt/ITNESSED B.V
T ! �" _ AERCOLAT/ON /*ATeF J Lesg
TOM M/ INCH
9O7 L 4cN/N�PER P!T SQ• FT L o.+'t r'-s• L o°ale - A--Al',
26 FT- �v/3sa aL svd��, 1��lCOLAT/ON RATE'A
MrAt LeACXING AREA. SQ z_ S ' _g
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�FNo.29874a jAr,(&> EL DREDGE EJV&41AfM)?1AW C492JNC:
/STtiR �pQ` • $�,E L L �, 7/2 I►►A/N Sr.
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wo GRoi/ivD w,a rtR �Jvcou/vTfxEo •
GROUvo W.. 7.5R A E'LE✓, .JOB ND`
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for.4 years). A business certificate ONLY REGISTERS YOUR NAME in tow
you must do by M.G.L.-it does not give you permission to n whic Y p operate. Business Certificates ( h
Main Street, Hyannis, MA 02601 (Town Hall) J �'tificates are available at the Town Clerk's Office, 1" FL., 367
w a iaikC� �^;r3 "y' DATE: 10
� hrtz vF � a 4 APPLICANT'S YOUR NAME/S: h Fill in please;
, t�1a .
M my,*f; BUSINESS YOUR HOME ADDRESS: F� / M ,�
TELEPHONE # Home Telephone Number
NAME`OF CORPORATION: To /�
�,n c
NAME OF.NEW.BUSINESS y^ ,
r�
ES TPE OF.BUSINESSIS THIS A HOME OCCUPATION? Y
D /
P�"fvrJ
ADDRESS.OF BUSINESS
pa 6 /
MAP PARCEL NUMBER
.. . (Assessing) .
When starting a new business there are several things you must do in order to be in compliance with the rules Barnste'ble. This f and regulations form is intended t 9 of the Town of
o assis
t you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE.
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH
This individual has been ja#,orjnd,pf the permit requirements that pertain to this type of business.
MUST COMPLY WITH ALL
YiAZA
Authorizeedd Signature*** RDOUS MATERIALS REGULATIONS
COMMENTS:
3. CONSUMER AFFAIRS (LICENSI G AUTHORITY)
This individual has bIn inf e o the licensing requirements that pertain to this type of business.
COMMENTS: Authorized Signature**
•
r f
C.� Sewage. Permit No.
Location: �� 'A-b 3 ff—r eR100,C> jam'
i
Village:
Installer's Name & Address . AEI C
1purE t b-71 hA
Builder's Name & Address PAA&iL= EDGE
Date Permit Issued
Date Compliance Issued
�ro�.
Fi
TOWN OF BARNSTABLE Date:12
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: '-Mqt 0,,, _P/tA m h in !� He k nf-,
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: (�E��kW o„ D. �'�N�c�v,'1 IE /L1 A, 0.)67k TOTAL AMOUNT:
TELEPHONE NUMBER: ( 7 -aL 9/ _ 6 q c e jll
CONTACT PERSON: 0,9
EMERGENCY CONTACT TELEPHONE NUMBER: CAI Ie'y W1;Z7'-'2S S ON SITE?
TYPE OF BUSINESS: '� 6,'►�s ��c� ��'►�1c
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: 5 o f l� WAS+ Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes PV C — (sl L � eNG'✓
Laundry soil &stain removers
(including bleach) A C ,c lew,
Spot removers&cleaning fluids
(dry cleaners) �P
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicigratar taff's Initials