HomeMy WebLinkAbout0102 CAP'N JAC'S ROAD - Health 102 Cap'n Jac's Road
Centerville
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No.2-153LOR
UPC 12534
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TOXIC AND HAZARD4OUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: �,-/A/7l �� Mail To:
BUSINESS LOCATION: IDd a4a J,4C le (�d - Board of Health
MAILING ADDRESS: 60X b 3q_ 'aSFV VJUI( Mg. Town of Barnstable
P.O. Box 534
TELEPHONE NUMBER: �h�" '�C�D Hyannis, MA 02601
CONTACTPERSON:
EMERGENCY CONTACT TELEPHONE NUMBER: .5AM it
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO y"_
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) CAW. Drain cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
2 _Pl_ Motor oils/waste oils Road Salt (Halite)
AL_ Gasoline, Jet fuel Refrigerants
. Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
- Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
-Paints, varnishes, stains, dyes 1V IbS. Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
_3� Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers S Any other products with "Poison" labels
r Metal polishes (including chloroform, formaldehyde,
4�, Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
2CRVI; Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business
f 1
THE COMMONWEALTH OF MASSACHUSETTS
_ BOAR® OF HEALTH
e1r17A�.ial�.S`7+ ........................................
ApptirFation for Disposal Works Tontrur#inn trnti#
Application is hereby made for a Permit to Construct N or Repair ( ) an Individual Sewage Disposal
System at: s
................ •.. ...... G.--�------ . D L-n'T
.................. --......-.....-----------------------------------------..............------.
Location- ddress or Lot No.
® ------------•---------------•-•-----. ........__
wner/• '" Address
a cArx�zn� .. No �I m �:n
Installer Address
Type of Building Size LotA 3,_...trj&Q.Sq. feet
U Dwelling—No. of Bedrooms.._...`3......................................Expansion Attic ( ) Garbage Grinder ( 1�('�
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ..............:.............
.. .....................•.-----------------------------------------------.......----------------------------------.-
W Design Flow............!5 .•!T.........................gallons per person per day. Total daily flow.....��.�.�........................gallons y�
WSeptic Tank—Liquid capacity goO.gallons Length.._..___.... Width__----�®-"Diameter---------------- Depth-- --./ _.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..........I.......... Diameter....V;�-!..... Depth below inlet.__-5v..G _'Total leaching area.. Z....s q. ft.
Z Other Distribution box ( ) Dosin tank ( )
Percolation Test Results. Performed by. T _ .1 ................................ Date- �-�_
I s Pit No. 1................minutes er inch Depth of est Pit.__................. Depth to ound water.-_.........____.__..__.
Test P P P In
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------------------------------------------------------------------------- _
0 Description of Soil " JL._ ..�� .��f � �.... ......... �--- �......'1�s
x -E.,o----1-0---- 1 � �� 1 7a--------------------------------------------------------------------------------------------------------------
W -------------------------------------------------------------------•-----------------------------------------------------. =......---------------------------=-------------•------.._....--
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................ .f
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasJbDe rued by tnhe,board of he lth.Signed ... Jam- ...../-.............................. ...........................Date
Application Approved By...... ---- .........9.-.= x:?- .....
Date
Application Disapproved for the following reasons-----------------•-------------------------------------------------------------------....--------------••••••_.
----------------------------•--------...Q...-----------------....................................--------...........----•----------------....------..............................•.--Date...--•......•-
PermitNo......�?..7.-- —--- .------------------ Issued.......................................................
Date
1 �
!. q
No...13- -------S— 3 F>n$.....�, ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......Nk -M------------------OF.... r.A4s' `�.i ' _,5.:<_.......................................
Appliraftiu for Disposal orks Tonstrurtion "rrutit
Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal
System at• I
......C..' --•-•.a' -................................._ 0 ..TD.-..---•..... ...........� .1.........6..............................................................
......_.......
ocation- ddress or Lot No.
^'Y" G ... —A .........................
wne� . ddress
............................................ ....
Installer Address
d Type of Building Size Lot` ... � .Sq. feet
Dwelling—No. of Bedrooms....�............................................Expansion Attic ( ) Garbage Grinder ( 10
Other—Type of Building No. of persons---------------------------- Showers — Cafeteria
Q' Other fixtures ............................
W Design Flow.........5-'-'Or.......................gallons per person per day. Total daily flow.....33__0.........................gallons.W Septic Tank—Liquid'capacityDn _gallons Length.8.cr.6,.%... Width-._-_.t0-. Diameter-______-•__-•-.. DepthS. /M.6., r
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------I---------- Diameter....1.!L ...... Depth below inlet_ m.€z7.- Total leaching area..?.5?,.,,..sq. ft.
z Other Distribution box ( ) Dosing tank ( ) 'p
'-' Percolation Test Results Performed b SAX).-F- Y�............................... Date.
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to groun w ter.__..._..._._.._..._.__.
fq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
04 •-••----•--•--•-------•----•-------------------- --•-----------------•---...._...--•-••......--••._.........................................................
O Description �f-Soil.Q_.-`"- `7 )l�,S'a 1� _, .. - � �l`T ° "Of---6- �4-l.....--
v •: <J_.._ I ... 5 } 1 T1..... .................................
W .. .... ••-•-•---•-•---•-----------•-•--•--•--------••-•---•--••-•--•...................•----•----•------•-•----••••--------•--------............•-------------------•---......-•-.------
UNature of Repairs or Alterations—Answer when applicable......................................................._.........................._........_....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be-en- issued byI the
board of health.
Signed..... .............................. ................................
Date
Application Approved By...... c'.'„-... ...... ....................... ........ ..- A S'
Date
Application Disapproved for the following reasons:------••----•-----------•--•---•---------------------------•--------------------------------------------........
--------------------•-•----•---•-----------------------------...-•---•-----......-•--------•-------......._..---.....--------------------...........---------------•-------------------------------•---
e, Date
PermitNo...... L.^.....J5......... .............._-... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........OF...........(..... .?- !Yam.............................
Tntifirate of (-ontpliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed k) or Repaired ( )
bY•-------•------------•-----------------------------------------------------------------------------------------0-----------------------------------------------------------------------------------
staller
at.............�'.pT....--?.......� ill---------
�.4 ................ �2� .....................
has been installed in accordance ith the prov ions of TI IE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....tr_7.=... ..�.. ...... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................. -. .- ............................... Inspector.....------•. ---------------------------------------------------
�"`
THE COMMONWEALTH OF MASSACHUSETTS
cc BOARD OF HEALTH
No. :.. 1..� ........ Iz`t_..........'OF...........1 . r :---•......................... FE � ...•-
Disposal Works Tonotrttrtion rrutit
Permissionis hereby granted.................................................................................................'------.................-•-•-•---........ .
to Construct){") or Repair ( ) an Individual Sewage Disposal System
-at No........ Q 7 --------- ................ +�� 5---------- --...... _� ....................
- Street
as shown on the application for Disposal Works Construct' Permit No __ 4..3..,.1...
,)Dated______ __ ...............
...........................................
1
DATE. /CL _�.. ......................................... Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS '`•...,`_,,,
TOWN OF BARNSTABLE r
LOCATION It,. R ,r�Tti ,� c :�-Rd - SEWAGE # 87-SQ'j
VILLAGE Ceyntergillet; ASSESSOR'S MAP & LOT / MQ
i
INSTALLER'S NAME & PHONE NO. dammett �C�or�etrnr f i nn :g�isl =7��,
SEPTIC TANK CAPACITY 1 ;000- GalTonk�,h
LEACHING FACILITY:(type) 1pi t (size)
r
NO. OF BEDROOMS_3_PRIVATE WELL OR PUBLIC WATER »hl i c
BUILDER OR OWNER Jerry. Phil1 i ns ,T
DATE PERMIT ISSUED: 12///////31-87
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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IJo GARBAGE. �j2�h1DEt2
KJ
i
UlAiLy FLOW 110 X 3 = 3306.Pn
jE.PT1G TAtiK = 330x15o% = ,49i6.PC> //
• v 56- t o 0 o GAL. % � � �r� �� t
o15Po5At- PiT v5E t vo0 6AL. � �
37 5 G.P�
BOTTOM A2EA- , 5O � �
5O $.F— X 1. O - rj 0 ��.P �OF ' '� _ TA-1c �`r
`, `
-rOTAI— t]ESbGN = dr2 t7.
—Tc>TAL- DAIL`( = —OtI.( = 3306.Po
PE.tZCOLATION RATE : I"IN 2MIN 0P�LG6 0
00
5 a�.1`_S. � �„'Vt,v(tiJ•�. +-0IY ji�' � 'J:.._....iJ } £,i".1 \�� /t � .�
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pt`6T. INS. �iEPTIG
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NO SCALE 5CAt_E. ATr=
1 CERT%Py THAT 'TNT ?� .fit( l? SNowN
►AER EO W GOMFLN` 5 YJITP-THE S I ot~L►N r-- (�
AVAP 5ETeAC, fL6Q01P-etAEN of -rWE-
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LOGp.TED /
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BAXTE1Za 1.!`{E INC. f
REG i S"r f-.C6•-D t-AW o S u IAYoF-•5 I
71.11g Pt_&IJ 15 NOrT Eat sc D otd AQ C?57E ILLB o °�S
No....... 45 I 1 I o
THE COMMONWEALTH OF MASSACHUSETTS
,A,r° BOARD OF HEALTH
.......... %t"�.---.... O F...... .� 5.±..1�?c.{ ..---•------•---•---...---•--_....
Appliration for Dispas ai Works Tonotrnrtinn Vamit
Application is hereby made for a Permit to Construct ( ' ) or Repair ( } an Individual Sewage Disposal
System at: �,�
u.1.S&W_(L.... ........... 4 :�.....................................................
Locati Address or Lot No.
{ 1 .�. •�...... lye T.t1-•-------•-----------•----- ..............G.A.R,11 = (' L ... ...................
Ow er Address
a ..........
Installer Address
Q Type of Building Size ---Sq. feet
V Dwelling—No. of Bedrooms...._..._ .Expansion Attic 00) Garbage Grinder 4jo)
Fi
p`4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------- -----------------••••-•_._.....
W Design Flow.......�IQ...........................gallons per person per day. Total daily flow.......Sao........................gallons.
WSeptic Tank—Liquid capacity.10 gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing pnk ( )
'~ Percolation Test Results Performed by...... _ ................ Date........._-• — �_j—_ 7 .__..
aTest Pit No. 1................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------_.................
Descriptionof Soil_. ..°./�--•.....i ..........................................................................................
------------------------------------------------•---.......-----------------------
W --------------------------------------- A-3----•. ------5{\ % .!�_k' :
UNature of Repairs or Alterations—Answer when applicable...................................................•........._....____.........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'i!L- 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 board of hfalth.
Signed..... --------•--- •.... . '---�
Application Approved BY.................-.................. -_ p y n�te�
Date
-
Application Disapproved for the following reasons--------------------------------------------------------•--------------------------------------------------------
----•------•--••----•-.........-•-----•---•--• ••---•---•---•--------•••-------•--...--•----•-•-----••-...----..._----•.................................................................................
Datx-
PermitNo......................................................... Issued.......................................................
Date
r
Vt
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................................................
Apli iration for Disposal Works Tontrurtion ami#
t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
...... ..........��-t A
...............`......... ...................................
Locat' n-Address (�or Lot No.
----------
Address_er ..... ..��O ...... :.- A oA.�------------------------------------
Installer Address U V Q Type of Building Size Lot..__..__+______________....Sq. feet
Dwelling—No. of Bedrooms........13--------------------.----------Expansion Attic 00) Garbage Grinder/VO)
Other—Type T e of Building ......_. No. of persons............................ Showers
a - yP g ---•---------------- P ( ) — Cafeteria ( )
Otherfixtures ----------------•-------------------------------------•••-----••-•-••••-••-••-----------------....--•••.....------...............--••••............--
W Design Flow.......\1Q................. .........gallons per person per day. Total daily flow.......�s.n.........................gallons.
WSeptic Tank—Liquid capacitylOgq..gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing ank ( )
a Percolation Test Results Performed by...... C�__ ... ._. ....... ...._.. `Date .._... :_
0-�
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ...........................................
- .......................•---..._.........-••--•-•-•--•--•----------••-.....----•-•-•--•-•-••.--•-
------------
,`.. s
D Description of Soll `. �, = n ,p -------::_5.?:---•I•-------------------------------------------------•------------------------•-•----•-------.
-
---------------------- - ----------- --` - U ar
1 •----------------•---------_------......
Z.
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 TITIE4 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued byte oard of health.
Signed. =� '. . --- ' , ...................
/ T
Date
Application Approved By•-•-••••-••---••-•••-•••••-••-••...-••••-•--••-----••-••-•---
........................................
Date I
Application Disapproved for the following reasons--------------------------------------------------------•--------------------------------------------------••--•.
..............•-•••••••••--•-••••-•-••-••---•---....•••••-•••......••••••-----•••-••..__...•••••-•-••-•--•••-•••••--••••-••••••••-•------•------•••••-•--••............................................
Date
�. Permit No--------------------------------------------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ..o ..IQ.......OF............. .4k.R.iV . AL4.54..ve...................
(Intifiratr of Tomplianrr
THIS IS TO CERTIFY, T at the Individual Sewage Disposal System constructed (`''�'or Repaired ( )
by.........._.ULT__ _if .......................................
�} Instal lerr.^
--•--•. ----------------- ....__ _. _.t:,� ,T .H_ .. _�' �!' E.............................................................
ND-
at !
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated_._.-____________----____________-•--•--•--•._-•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCT10Nri-71
AC ORY. �j
/�. _..-- -•-- Inspector. / `� -.... ......
DATE................................ ....
.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................................OF.....................................................................................
No......................... FEE........................
Disposal Works Tons#rurr#ion rrnti#
Permissionis hereby granted.........................................................................................................................................
..._
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo....................................................................................................................
p�
Street /( --
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
---•------ ------ -==
----------•-•---•-•--•-•............................. Board of Health
DATE------------------•------ �.
FORM 1255 A. M. SULKIN, INC., BOSTON
I
;' up GAt2BAGE (�QILIDF2. �
c�n.I�•{ FLow 110 x 3'~= 3;r;3oG•Po ,� � S IS xt ,�-�
SEPTIG TAw�K = a3oxl5•o% = a9rG.Po / 4 j
u5c- %000 GAI- y
o15Po5nL PI-r v5E 1000 GAL.
S 1 EPSWALL AV-SA, - 1 50 S.I?
�50 S.F X Q
so-gQST.Fx AI•oA � ��.P o- , � : , ,, •�t 0 �tln�x T
WO M*
�ToTAI-
ZoTAL DA 11-Y F%-C>W = 330 6-Po '� �;� "� 3S_.c N
PEq,COLATIOR PATE : ITN ZMIN
2- 4
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,
RICHARD
PAXTER
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<qt GIST�~4
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Zyi ,coo ,Nr Box //s L -TANK
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LOCATED WITWW *T%4 FLvoD P &1►4 11 (ZB�g3
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bES1G>y; �A'�A `�/4�8� � � Co►.1G RiStc'�
, tNC�L �Pr •M!LY: 3.-gDR9oM : F.L'1,19,5 GG 11
1 8 O
AQ� CsPIRSAGE. f�R1NDER i FG I1.7,2 TOPSO.II
8R• X 1 IO G;Pol13-ri = 330 rzpt> �t INY 115.0
5 u t35Q1 � i 5 `..
5EF^l IGTANIt 3;3,a!k 150./o ? 9,5GRt, v.� GOO t00� GAL 'IN1/
,_ U5� io:Oo TA1.1.K I1�N SF_PTIc
u , GRgVEI. ` GAL > 1Ml It5.8 n�ly
1/ 115 TANK A
L�GAG-1
r; t-EAcH.Fg.0 1 L 17Y t 1
IT
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I N S T A LLER'S NAME i ADDRESS
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DATE COMPLIANCE ISSUED
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