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Home My WebLink About0330 ELLIOTT ROAD - Health 330 Elliot Road Centerville 77-095 UP2153L V%w �ww�rr YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. -.it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: of L— Fill in please: APPLICANT'S YOUR NAME/S: I 30 P Z C BUSINESS YOUR HOME ADDRESS: — — ^-' v 66z 1, �D , '1 0- O-7 n. Q TELEPHONE # Home Telephone Number ' i a :.s?...,r...,,...;7 ,.,,.,.z� EMAIL: F��j/oGF��I !�^�. C� NAME OF CORPORATION:. NAME OF NEW BUSINESS L CoM C I TYPE OF BUSINESS N 1 IS THIS A HOME OCCUPATION? YES NO (' 2 ADDRESS OF BUSINESS.33� — '( n i�L. � 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 and regulations of the Town of Barnstable. This form is intended to assist 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 COMMISSIONE 'S OFFI This individual has be orm o n rmit requirements that pertain to this type of business. Author dSi atur -- COMMENTS: i�n n 2. BOARD OF HEALTH This individual has been inf r e i requirements that pertain to this type of business. Authorized Signature COMMENTS: 3. _�.._._._ _'LICENSING AUTHORITY.. This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: _ c t!7 r N � N A � 7 Z - b n _ � N i Iv� } J f .L C 6 9 3 � `O N CA m o F o 3 g c s I X )` 1 � f" � r3 VN P x 3 K 4 R (n V. C p .O r• n mMMM `;> �t c 33. z CD C. ;;mow 7z w D Y cg N ? r V T (/ 77 Resi PaB� N yeatam taai.{aniiaL ! I e +d.T q -_Cdl_78tr6563298 .. - .. Capyrighl C Raaidwlielpi•.e. d.etgn.d h'r2�1�Ay1 tn II Att dirn.n.i.ft gi..n•n.ubj.tt to job irta Not.:Slrudur.l J wb by oth.- Nalc Pmpactiw drawing.r.present th.•rt Wx iMerpr.ution of iho gmml .rip—ti—•wd.d)—t—t to At job dl.c"dutle.,. app-,.".0 the roern and.re net inta.d.d to b.•P—I.d.P4r io.. The first step in the design process...see it before you be inl Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M.0 33 Property Address J P� c ✓ll// ?l Ow ner Owner's Name ;t� lnsp information is Clo ey-vl I e requiredforevery State Zip Code Da ction page City/Tow n Inspection results must be submitted on this form. Inspection forms may not be altered Inany way. Please see completeness checklist at the end of the form. Important;When A. General Information form I �G� 2I filling out for J on the computer, use only the tab 1. Inspector: JJ key to move your / /S cursor-do not ,c V►1 use the return Name of Inspector �/,/ key. O 7 Company Name �t7 /�0 Company Addre5s1��< yl G !^'� � A) b C/i (� State Zip Code CitylTown Telephone Nu rMib 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. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000), The system: Passes [IConditionally Passes El Faits ❑ Needs Further Evaluation by the Local Approving Authority In_,p_ecloirt 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 clod 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. ""This report only aescribes 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 501ficiel inspection Form,Subsurface SewageDisposel System-Pagel of 17 t5ins•3l13 O V Commonwealth of Massachusetts _ - Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a -- y 3 3 v cell o �-- aCj Property Address JJ �P v►c'2 t� Ow ner ON ner's Name information is CQ H V� ` ,e �� // l/o�10 required for every - Zip Code Date of Ins ecti page. City/Town State B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System P s: 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: 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): t5m 3113 Title 5Official iris pec,tion Form.SutuuiaceSewageDisposal System-Pege2ol17 Commonwealth of Massachusetts r Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 0 Property Address l Cw ner ow ner's Name Cc /information is - �✓��` e 0) 6 O required for every page. Ci Town State Zip Code :Date of I spec on 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 mannerwhich 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 151ns•3!13 Title 50le ncial impoctio F orm Subsurface Sewage Disposal Srtem•Page 3 of 17 l Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address ow ner Owner's Name Ce information is required for every page. 5Tow n State Zip Code Date of Ins ecti n 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 DEP certified laboratory, for fecal 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 for clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than'/s day flow l5ins-3113 Title 501hcial impecucnf orm'.SubSLeKe SOWB90Disposal System Page 40117 Commonwealth of Massachusetts jig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Qv1�Q✓ ON nerrm ON ner's Name information is required for every State Zip Code! Date of In ecti n page. CityfTown B. Certification (cont.) Yes No ❑ U 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 nitrate nitrogen 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 attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,OOOg pd. ❑ The system �. 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 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 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. Title 501 CIN InspecoonForm SuWurtme sewageolspow system.Page 50t 17 t5ns•3113 1 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Cj Property Address N 1L Ow ner Cw ner's Name / l / 7 information is Ceo �ev,✓1 o l/o�t �, �O 6 required for every page. CitylTown State Zip Code Date of Insp6ctiov C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes o ❑ 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? ❑ as 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 NIA) 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: Q [�� 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): Number of bedrooms (actual): ^� Jo DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 6ris•3f13 Title 5 Official Ins Poc tiai f'orm SUbStrf ace Sewage Disposal System•Page 0 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form M Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address re N Owner Owner's Name �()C�C'To� information is H-�t/f// ` : f required for every State Zip Code Date of Insp tion page. City/Town D. System Inform tion Description: / /Ono / //� P J� (.T T A N �G/ r� Number of current residents: ,,_ Does residence have a garbage grinder? El Yes P No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonaluse? Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: 5a a Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: t5tts•3/13 Title5Qf%lal inspectlonForm subsurface SewogeDisposal System-page 7of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1l2j Property Address /I �NCQ� ON ner Pni ner's Name information is CC 0 4C4/t// required for every State Zip Code Date of Insp coon page. Clty[Town D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Cox Source of information: ---T' --- Was system pumped as part of the inspection? ❑ Yes Er No If yes, vol ume pumped: gallons Howwas quantity pumped determined? Reason for pumping: Type of S m; Septic tank, 0990055A soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy l ❑ 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): TiUa 5 Official ire poc Gm Form Subsurf ace Sewage faispoaal Syalem'Pape 8 of 17 t5ins•3/13 . l Commonwealth of Massachusetts Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form - Not for Voluntary ssessments Property Address ON ner Cw ner's Name information is / �� yt� �20) /Q required for every �✓ page. CitylTown State Zip Code Date of Ins ectioff D. System Information (cont.) �o Approximate age of all components, date installed (if known) and source of information: 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 T40 PVC ❑ other(explain): _____ /a 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: feet Material 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) ❑l Yes ❑ No Dimensions: S 'X l3 Sludge depth: /l t5ns•3113 Tille 5official Inspection F orm Subsurface Sewage Disposal System•Page 9of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 2-3 z:1110 Property Address / P�Ole✓ Cw ner Cw ner's Name l / information is C e V1 4e,f yI e- AX � C.,required for every page. City[Tow n State Zip Code Date of Insp ction D. System Information (cost.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): c;iv° lv o , g/ Grease Trap (locate on site plan): Dept h bel ow g ra de: feet 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: Date t5ins•3113 Title50fftcial Inspection Form sunsulace sewage Disposal system Page 10of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Pe e Ow Off ner's Name informrrn ation is e V,—��i/(// required for every State Zip Code Date of Insp ction page. City/Town 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 TiUe501ficial impecUcnForm,Subsu-I ace$DwO900 405el System'Page 11 ct 17 tans•313 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address Ow ner Cw ner's Name P� information is �'f//��i/t required for every State Zip Code Date of In ecti page, GtylTown D. System Information (cont.) 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 leakage into or out of box, etc.): AD d o 4:-�i s CA 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: Tito 5 Official Ins pec tion F am SUbsUlace Sewage Disposal System-Page 12 0117 t5l ns•W 3 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments pT 3-3 ko As es Property Address ON ner ow ner's Name information ism (��/✓j (�o�� ` /� required f or every Stale Zip Code Date of Insp coon page. City rrown D. System Infor ation (cont.) c,� a o Type. 0 leaching pits number: — ❑ 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.): -LK 4 /'G,I.- 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 C] Yes ❑ No Tile 50lficiEr repocUmForm SurALeme Sewageolsposal System Page 130117 jSrs•3113 Commonwealth of Massachusetts w-- Title 5 Official Inspection Form L Subsurface Sewage Disposal System Form - Not for Voluntary )fAssessments Property Address 3,30 Cw ner Cw ner's Name information is 6�C 7� required for every4� � Leo �i `e page. Cityrfown State Zip Code Date of Insp ction 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,): tSns•3/13 Ti0e5OfAcial InspoctlaiForm Subsurface Sewage Disposal System-Page 14 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary ASSArS�J.monts Property Address ner Ovv ner'S Nar inf rle information is CeN��- /e 6 required for every page. Cltyrrown State Zip Code Date of Ins ectio D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two ermanent reference landmarks or benchmarks. Locate all wells within 100 feet, Locate where lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately FR oiv i 2� . It3 - y-p IYJ - 30 t51ns•3113 Title50fficial inspectlonFam Sut�strface SewageDlsposd System-Page 15of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System /Form - Not for Voluntary Assessments Property Address Pe Nc�lr Ow ner ON ner's Name information is required for every l� page, City/Town State Zip Code bate of Insp ctio D. System Information (cont.) Site Exam: C� ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: pate ❑ bserved site (abutting property/observation hole within 150 feet of SAS) Checked with loo(;aJl Board of Health -explain: /q JIes ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must descrjge w you established the high round Ovate levation: o ✓"I d �G �'/// 9' otc/c, L4 7LU To )W L/ o C- WO Before filing this Inspection Report, please see Report Completeness Checklist on next page. tyrs.y1$ Title501ftial Inspection Form Suosulace Sewage Disposal System Page 16of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments //10 4 Property Address ON ner ON ner's Name information is C��- r/(/� 1 e Ud�6 /0 A7 required for every page. City[Tow n State Zip Code Date of ln#ecticfi E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Ea S tam Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ris-3113 Title 5 COON Ins pec t7on F orm:Su bsuf ace Sewage Disposal System•Page 17 of 17 No....73--_. /FEz ..d..... _ THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH Barnstable Conservation Department TOWN OF BARNSTABLE ��`r .sue /—/9 -51 .? Apphration for Dirpnial Wor1w TowitrurtiN ermit Date-- Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at:. erg . j� LmZlion-Address or Lot No. Owner Address �, Instiller Address Q Type of Buildings Size Lot............................Sq. feet U Dwelling�No. of Bedrooms.---------------------------------_.Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons----------------..-----_--. Showers ( ) — Cafeteria ( ) Q, Other fixtures ........................... ................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.-..........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 tank ( ) a Percolation Test Results Performed by........................................................................... Date........................................ 04 Test Pit No. I................minutes per inch Depth of Test Pit.-.--.-------.------ Depth to ground water------------------------ f4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a .......................•--•-••-•-••........---...........................-•-•-----•-••.._._............._......---........................._....---•-•-•-•-- 0 Description of Soil................................................. --....----•---••------....------------.•-•••...---••-••••••-•••-•••-•-•---•-•••••••-•-•-••-•-••-•-•--•................ V ........•••-••••••••---•...•••••••-•-•.......-••-•--••••••-•---•-•---•--•••---••-••-••-..........•••--•-•-•-•-----------•••••-•••••••-•--•-----•••-•----••-••-•-••••••--........••--.........•-•-••••••- W •••-••••---•----------------••-----•-...••-•...••-••--•...---------...........----•----•--•.............----•-•- UNature of Repairs or Alterations—Answer when applicable.......!. �J-- -�714?...-......_... n.�/ l�.__i%!...��1(r�..ow ............................. --•------------•-----•-------•----------...--•--•••----••••-•_•-••••--•••••--••••-•-••-•---•-••••••---••••--•--•••••••••--••••--...-•••-•••-•••......--••••-•----••-•••... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the b a d of health. Signed .c� l /—r/q Dace Application Approved By .... ....... .. .. ...................... �:-19 -.1.5.. DaceApplication Disapproved for reasons: ........................................... ........................... . . . . . ...............cc.................. .. .. . ................ . . ........................ . ......... ........................- ey Dace Permit No. l 7j..^_...'.c�.6-----------------_------- - Issued ............................................... Date ; ,,,� -s1=:r'r.�. _.:--,:_.-..,,r' ;. .:---+w-..-•�..'+t;., :3�>+ �: ..r...�S.,y,J "i�'a.,....-''"'Yf.-L.v �,�•r'—.,�.,c.-.,,� ..:�,a' ..:t,��+- •,..,:�y-_:..�,�+ - ;u. No.... Fxs......... L��..O..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �i_,1�7� Appliration for Di►ipmial Hlorlio Tonotrnrtion "rrntif Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 330 ..-•_.... ...__-•---- .... .. ..........=........................................................................ Location-Address or Lot No. hI .CI.S'_._ ....O t v n ...__...._ Owt er Address ....yw DVj ---••--•--------• -•--•-•--------•-------••--•-•----------------d--d--•-ress--------------------------------- -••......... � �Installer A UType of Building Size Lot............................Sq. feet Dwelling o. of Bedrooms-�_________________________________-_Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons----------............_..... Showers ( ) — Cafeteria ( ) 04 Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity-__-.____-gallons Length______________''Width................ Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter..._-.----.-.-._---_ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 4 Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground. water........................ Gi Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................ I+ •--•-- --•....................................•••-••----•----•----------••--•--•••-.........---.............--••-••---•--•••--.....................•--•---••- ODescription of Soil............................................................................. .......................................................................................... x W •-•--••-----•------------------------------•----------------------------------------------------------------- ........ � - ` U Nature of Repairs or Alterations—Answer when applicable.----- �c.7.<,t_._�>>z<<_�..." ..__...__.1. : ._��✓�?.TT� ----------------------------•------•------------------------- ------------•---------...........------•--•------------------------------•-------------------------.......__.._..........•-•-.........---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the by a d of health. Signed �� ...: . �.� -- 3�. .......... ........................... ........ Dace Application Approved By -----------(J J ..../......� --- Dare Application Disapproved for the following reasons: ...................................... . ......................... ... ...................................................... .................... ....................... . . ........................ ......... ... ......... . -- ......... ............................. .. ........................................ cy Dare PermitNo. ........../.....3. ..----�-�...... ................. Issued ................................................... --.......... Dace I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE V-Ertifiratc of Taraylialare THIS IS TO CLRgFY That the Individual Sewage Disposal System constructed ( ) or Repaired by......................:.................... o�o.'�... .v- �.S............. ..,........... ..................................................-...-.... ..... . . 3 3 0 �I.I l i �� ................ ... ....................................... at ............... ......................................_ ....A .............._...... has been installed in accordance with the provisions of TITLE 5ofThe StaEnvironmental Code as described in d the application for Disposal Works Construction Permit No. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. l - Inspector ....... ....�..� 1-�.........:. DATE .. .........1..... -......... .. ..........._.-......_ p .. ........................................._.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No...... 3 TOWN OF BARNSTABLE 7�.,_... FEs...-}..O_..... .... MiVooal Workii Tonofrtrtion "antit Permission is hereby granted.......... ---••--•----....--•---•••••-....-•......................................••--......-------•- to Construct ( ) or Repair (�an Individual SewageiDisposal System � r at No. 3U. IF I t-•-•-•--•-- ��` P= -/"-•------........- . Street 5 as shown on the application for Disposal Works Construction Permit No. .___'_____________ Dated______..............._............_._._..__ ....... . -- ---- /�pp�^ Board of Health DATE...........)....... 1-(._..._.. ... v FORM 36508 HOBBS h WARREN,INC..PUBLISHERS TOWN OF BARNSTABLE ,LOCATION 3130 SEWAGE # q3-aX VILLAGE C�r( Ir—rcl/, 'ASSESSOR'S MAP & LOT Q�`j { INSTALLER'S NAME & PHONE NO. Ll.a 8 �cCc SEPTIC TANK CAPACITY /000 001/4-,j •r C LEACHING FACILITY:(type) (size) oho �) NO. OF BEDROOMS - PRIVATE,.WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: l / VARIANCE GRANTED: Yes No [� Q® CC S-j w � e J i