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Home My WebLink About0134 ENSIGN ROAD - Health 134 Ensign Road , Centerville CP/R - - A = 147 064 rrr J�¢�CYCLFnro� irr A M UPC 12534 No.2-153LOR HASTINGS. MH Q 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 the 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, 151 FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. DATE: 1.. Fill in please: APPLICANT'S YOUR NAME: O . n.8 BUSINESS YOUR HOME ADDRESS: , t TELEPHONE # Home Telephone Number: gZ NAME OF NEW BUSINESS 5a3OZ7C`�l t,ffG� TYPE OF BUSINESS r � IS THIS A HOME OCCUPATIONN YES NO Have you been given approval from the building division? YES NO ✓ 2 ADDRESS OF BUSINESS CVAP/PARCEL NUMBER 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 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 h s bee forme f tiT-D-ermit requirements that pertain to this type of business. MUST COMPLY WITH ALL HAZARDOUS MATERIALS REGULATIONS Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual ha inform ' f the lic n 'ng it en�ts that pertain to this type of business. A hgrized Signatur ** COMMENTS: !�/hi;c�_Q (L �Q r Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: L- !4 BUSINESS LOCATION: �3 _a-;- INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER- CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: T 1C;, C::Ayy—n INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: 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 materials 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) Misc. 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 Misc. 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 Misc. 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 (inc. carbon tetrachloride) ` 'NEW- Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor & furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids R (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS d+ra+w� i -,s �c�, 4.�}�.. s •+ . TOWN OF BARNSTAELE Date: TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: ��`� �'�'n C �iI �t--et� 02�32 INVENTORY MAILING ADDRESS: �- � TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: r& t� C—'1 - "S INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: 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 materials 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) Misc. 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 Misc. 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 Misc. 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 (inc. carbon tetrachloride) - E1NLJ'S�D Any other products vuith�`poison" label's� Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: /4ll�P4 g OM66A ?A i,y t'E,2 A�,, BUSINESS LOCATION: 13LI 6�S GN RD 0"'� MAILINGADDRESS: SAne Mail To: TELEPHONE NUMBER: 5bg- 't3'& Board of Health CONTACTPERSON: E-vLAL-Vj FfAA16A Town of Barnstable P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: 5o,�6-1a6 - cf 9+S Hyannis, MA 02601 TYPEOFBUSINESS: PAI/j rr'N G Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO X 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: I3k 6rs; 6-n1 P3 MA C6vERrO TELEPHONE: POY 4( 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. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED - Cesspool cleaners Automatic transmission fluid - Disinfectants -- Engine and radiator flushes - Road Salt (Halite) Hydraulic fluid (including brake fluid) - Refrigerants Motor oils - Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel - Photochemicals (Fixers) -- Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, - Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal - Printing ink Degreasers for driveways & garages - Wood preservatives (creosote) - Battery acid (electrolyte) - Swimming pool chlorine Rustproofers - Lye or caustic soda -- Car wash detergents - Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers l® 64 Paints, varnishes, stains, dyes - PCB's -- Lacquer thinners - Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) I air Paint & varnish removers, deglossers GA.,._. Paint brush cleaners Any other products with "poison" labels (including chloroform, formaldehyde, �- Floor & furniture strippers hydrochloric acid, other acids) Metal polishes ^' Laundry soil & stain removers - Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS �V,,ll0 J 3- g to. ` Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for ]0igpo!6a1 bp5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 0 Complete System El Individual Components Location Address or Loot No N�`i /V j D Owner's Name,Address and Tel.No. Assessor's Map/Parcel j _o I aller's Nwne�,Address,AdTe•1.No. Designer's Name,Address and Tel.No. 1 V laa4-5 1-7g'19CI S Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title "ZN1l;\1G f=� "1 �r ram- Size of Septic Tank Type of.,- Ai C `'HFY l?1 Description of Soil �' �� n V • f'P.�41�l, Nature of Repairs or Alterations(Answer when applicable) I s`� Lu Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by this Board alth. Signed Date f0/` I3 Application Approved by S. Date lblyleo Application Disapproved for the following reasons Permit No. Z� 3� `�y Date Issued /6 5..0 I V 3 —1 / Fee . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS ZIpplication for Miopooal Opotem Congtructfon Permit H Application for a Permit to Construct( )Repair A.)Upgrade(p� )Abandon( ) El Complete System El Individual Components Location Address or Lot_- No. ,3�� O Owner's Name,(Address and Tel.No. Assessor's Map/Parcel��t J -0�� „•'`�Qi'/1 L L� T��y� I tallee s Name,Address, Tel.No. Designer's Name,Address and Tel.No. 'a 3 ►� ann'ls M�o�i Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date a Number of sheets Revision Date Title / Size of Septic Tank Type of S.A.S. Description of Soil A ! a.. Nature of Repairs or Alterations(Answer when applicable) ln Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this BoarYI&M-40- ealth. Signed Date wI 03 Application Approved by *Date�"-iu Y �3 Application Disapproved flor the following reasons Permit No. 2 C0 3 0 y Date Issued (� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS S� �y (Certificate of (Compliance THIS IS TO C RTIFY,that the On-site Sewage Disposal System Constructed( )Repaired�)Upgraded( ) Abandoned( )by _ -5 -S T7C_ at /Ai A )5 W / is has been constructed in accordance with the revisions of Title 5 the for Dis_osal System Construction Permit No. z��- ��l dated /o /X/0,� P , Y , Installer I /l�P � ! Designer �^ The issuance :e yt shall not be construed as a guarantee that the system wild a e ifo s"k e fined. Date -' I D�f'1 1 03 Inspector - L•� 200 3" --------------------------- --- — No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Migogar *pttem (Conotruction Permit 7Permission is hereby granted to Construct( )Repair Upgrade(, )Abandon( ) —System located at CAj,,S/6A) and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit: Date: 10 f Lk/D-3 Approved by J - i fl TOWN O BARNSTABLE LOCATION, 5�—c; SEWAGE #� 7 VILLAGE ASSESSOR'S MAP & LOT 141l 10 �q INSTALLER'S NAME& N TT SEPTIC TANK CAPACrYY �y LEAC�G FACILITY: (type) Z-j s t—c,6 VO4 (siie) NO.OF BEDROOMS BUILDER OR OWNE PERMITDATE: IQ. 3 COMPLLANCE DATE: 011 q103 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i i Ate !e AiCkj 19 Y � ! as ( TOWN OF BARNSTABLE LOCATION ��'t ee4!�'(J' SEWAGE VILLAGES 1 ASSESSOR'S MAP& LOT_L41-01ay INSTALLER'S NAME&PHONE NO. � ,SEPTIC TANK CAPACITYVJ LEACHING FACILITY: (type) <-�i y r-L6, "7— (size) a3 h A V N.OF BEDROOMS___ (� k:DER OR OWNE FQ TT DATE: 3 COMPLIANCE DATE: O O 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 19 ,T COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTETRE-CEIVED , E NO3 i TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP �1 Property Address: 134 Ensign Road PARCEL. �� 4- Centerville, MA 02632 LOT 5_ Owner's Name: Peter&Cathleen Tucker Owner's Address: 267 South Main Street Barre, VT 05641 Date of Inspection: September 12, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes ✓ Conditionally Passes Nee Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: September 20, 2003 .The system inspector shall sub t 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 The D-box was broken down and needs replacing. ****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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 134 Ensign Road Centerville, MA Owner: Peter&Cathleen Tucker Date of Inspection: September 12, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR .15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. The D-box was broken down and needs replacing. Answer yes,no or not determined(Y,N,ND)in the 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. 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 inspection if (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 i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 134 Ensign Road Centerville, MA Owner: Peter&Cathleen Tucker Date of Inspection: September 12, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or 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: _ 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 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 134 Ensign Road Centerville, MA Owner: Peter&Cathleen Tucker Date of Inspection: September 12, 2003 D. System Failure Criteria applicable to all systems: You must indicate either`yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an.overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 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. ✓ 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 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 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 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. 4 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 134 Ensign Road Centerville, M4 Owner: Peter&Cathleen Tucker Date of Inspection: September 12, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Weekend use COMMERCL41A NDUSTRIAL Type of establishment: Design flow(based on 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: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: Qallons--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) r A Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Jan. 6183-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 I Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 134 Ensign Road Centerville, AM Owner: Peter&Cathleen Tucker Date of Inspection: September 12, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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 r Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 134 Ensign Road Centerville, MA Owner: Peter&Cathleen Tucker Date of Inspection: September 12, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: r 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 leakage,etc.): 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:. 134 Ensign Road Centerville, M4 Owner: Peter&Cathleen Tucker Date of Inspection: September 12, 2003 TIGHT or HOLDING TANK: None (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: Rallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was broken down. Dirt was caving in. The D-box needs replacing. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 134 Ensign Road Centerville, MA Owner: Peter&Cathleen Tucker Date of Inspection: September 12, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): The pit had 3'6"of water on the bottom. The scum line was at the same level. The cover was 30"below grade The bottom to grade was 9'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 134 Ensign Road Centerville, AM Owner: Peter&Cathleen Tucker Date of Inspection: September 12, 2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 4A�kp\ �ou,k i I I 010,6 �86 a a a� 3a s ` 6 3 aq 3y yo y 10 i ' Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 134 Ensign Road Centerville, AM Owner: Peter&Cathleen Tucker Date of Inspection: September 12, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contour maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours maps, the ground water level was approximately 25'+/-at this site. This report has been prepared and the system inspected and conditionally passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 4C. LOCATION SEW-AGE PERMIT NO. VILLAGE INS , ER'S NAM a A 0 0 N F S S • m�*d.r�/,��r--yam -� .��o.� i+ U I L D E R OR OWN ER DATE PERMIT. ISSUED DATE C 0 M P L I A N C E ISSUED l ��. �� :. .' � �r �:. �� -. TOWN OF BARNSTABLE LOCATION Eels I ►n SEWAGE # VILLAGE Ce.,i trV,I t ASSESSOR'S MAP& LOT/ �O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACIL=: (type) (X(r ' ' (size) GA WO.OF BEDROOMS J B1;jsZ,OER OR OWNER rreler 7-Lit, PF» ,lT ATE: COMPLIANCE DATE: r'a'1t Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet. Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feei of-leac g facility) Feet Furnished by 1 UA �• �0� �)eGk a y 3� 1/0 No. .... . - Fes$......3 .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF j�,HEALTH ....0,6� ......--.OF..................1.1 F ''..$� 1,� ......................... Appliration for Uiipusal Works Tonstrnrtiun ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sew a Disposal System at: _._. ..... _. ........ .. .. ...'F.... ....� / S .�n. .....--- - A..._...-•-- 0 ....... ..... --------- ca'on-Address , r Lot No. .- •........................... . .. 1-la : ..- �*^........._. . C t #� ...,�lo. ..... _...... ner Address ------------------------------•---• r �l f�. c s c Installer Addres .... Type of Building Size Lot.... :Z___YA_7_Sq. feet U Dwelling—No. of Bedrooms___________ __ Expansion Attic ( Q Garbae Grinder ••--•--------------------- — Other—T e of BuildingNo. of ersons____________________________ Showers Cafeteria Q' Other fixtures - -•••••••••-••-•••••••••-• • W Design Flow...................... ____.........gallons per person per day. Total daily flow............... .............gallons. WSeptic Tank—Liquid capacity__J:0_4allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length...._............... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (,-< Dosing tank ( ~' Percolation Test Resul s Per by................... .� _ �_`�....... Date......... YZ_ __j__. t it-a--j(--- a Test Pit No. 1___(7-5 minutes per inch Depth of Test Pit____/___f Depth to ground water_. ' — (i, Test Pit No. 2.....:�minutes per inch Depth of Test Pit._.__.`------------- Depth to ground water------ 1!+-z4��`�' a •••••-•••----------------------------------- ---- --- { O Description of Soil------------------------------------------ _..._..-••••-•�•-•�••-•- . fo !$....'L........... x / � 1�._..._... !� e ----v-_ 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 iI?I, 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�heap. SI to ApplicationApproved By.......................... • ...... ...................................................... •••_.fl l - Date.............. Application Disapproved for the f o ing reasons: --•-------------------•-----------------------------------------------......._. .......................................................--------------------•---------------------------••••••••-••••--•-•••••••-•••••••••••-•-••------------•--••••••••--•-•••---••••--•••••••-•----- Date PermitNo......................................................... Issued_...................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to Construct or Repair an Individual Se-,y4ge Disposal System at: -Owner Address Installer Type of Building Size Lot... !�2_.Sq. feet Other Distribution box Dosing tank ( ) Test Pit No. 1...�:'.�.�.minutes per inch Depth of Test Pit.......&!m....... Depth to ground water... Test Pit No. 2_2.j�'44�"mmutes per inch Depth of Test Pit----- ............ Depth to ground water.... � ------`-----`-----'---------`-----`------`--------`------`---'-``'--'—'--`---------- the provisions of A'I T 11,14: 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 health. Date �a Date The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with � Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed--r—i or Repaired ....�/e /--- -------------------- has been installed in accordance with the provisions of TLITIZ 3 of The State Sanitary Code/s 'escribed in the application for Disposal Works Construction Permit NoV��4' ............... d-ated- .1 ' THE ISSUANCE OF THIS CERTIFICATE—SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI�k F�MCTION SATISFACTORY. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH to Construct or Repair an Indivilluf';al �ewage Dispos�d System as shown on the application for Disposal Works Construction Permit No.................... D Bo hIt FORM 1255 HOSES & WARREN, INC., PUBLISHERS � c ,'., �ytN OF tooft q �o unm NosuaV / i v � �la¢.4 lo�� tv e — Q o V G'A >' 7? c o AL�R toii/rN'C U HORS cn N�� 1CzM� V+I��` \ Mi�/.A%�E::� /svoo s,F. .o ,Q No.10951 9a.FG�STE? c) 2 U F. �FSS/ONAL .: LEGEND EXISTING SPOT ELEVATION Ox0 DERJt IritD r✓LuT PLwi EXISTING CONTOUR ——— 0 -- J-0 -r n/s! FINISHED SPOT ELEVATION FINISHED CON-TOUR 0 Al APPROVED BOARD OF HEALTH ` - 1N ` yA&K S t�1�3 l� ,.�1.�1�3 �s . DATE . AGENT SCALES l "= 40 DATE= 4 LDREDGE ENGINEERING CQ IN CLIENT'" I CERTIFY THAT THE PROPOSED EGISTERE REGISTEIREDI JOB NO 023 BUILDING SHOWN ON THIS PLAN CIVIL LAND, CONFORMS TO THE ZONING LAWS ENGINEER SURVEYOR DR,BY '.•�..q,/�. �- OF BARNSTA E, ASS. 712 M A I N..STREET, CH. BYE H YA N N 1 S,: M A`$.3 . SHEET OF DATE Rftd. LAND SURVEYOR :. IV 07E SFPT/C TANK OR EACsaiivo P/T ARe MORE rAf A,-/ /2"BEL01t/ MIA01. rRAOEM A 24'O/AM ETER CONC'R ET.E COMER SWALL BE B•QOUGHT To GRAOE.�.ti/V EXTRA CO/VCRtTE 4�PYC P/Pd tIEAVY CAST /RO/V COVER Shi,41-L pE USE17 MIN. PITCH COEES7,D /F/N/ R DR/VEy1/A Y ' � " 2 J"MiN. CO/VC.eL�TE .4oE Cd VE.4 CL EAN .SANG i L19wo LEVEL BACAe)Fl LL .',r 4 4..CAST .fir.; 2 LAYER AV v b MIN.P/TcN`, /"D'DO GAL. • •` v j • • • • • r• e�• yyASHFO 57'27NE .SAEPT/C ". 7i4Nf( D/ST, •'b • • • • • • a• • • e a BOX o • • B • • • • • .•P • • w • P • •EFFE lCT/✓G ' . r 3 4'= �2 ` ¢ ,Y t • ° 0 • • DEPTH • • • • • • 0 WASAFP STONE (88S x Q,5 4�T6./D Apo � • . • • • • • • o.p PRECASTSEE.PAGE j �lNfiSRT'ELEY.4T/oArSS.S <,X i:o �S G/� ►.� r • • • • • • • •o P/T OR �V/Y. I /NYERT A7 04I.&DING P'7 5 4`�! 6 D /O" p/ .J SEE TABULATION /NLET. .S'EPTIC TANK .: :: IOZ,S FT:: LT c,kPAc r,! � FT i4W. ; C( :Ogrz:er SEPTIC TANK': GROu!YD. Ot>TLETD/STR/BIITIONET�V�G.E - S /IirY ET LFACN%MG:-/ /T d fJ, O/SPOSA L. SYST,EM - �. -- LEACf//NG P/T . 7A BULATIDN DES/6N" CRITER/�1 3cALE ��" /• o� N ( _ DIMENS/O FT Gf+RBtGEo/sl�osAL TQ.TAL E3T/MATEG FLOW 3 3 a G.4L./oAY SO/L TEST liE/ ' SOIL TES7-02 SD/L TEST NUMBER OF LEACMtNG P/TS fELG•Y /O 3.3 ACLIeY. ,DATE OF SOIL TEST SIDE LEACHING PER P/r S41 FT. I BOTTOM LEa�ICN/NG PER PIT 7 $Q,',eT. RESL/LTS N/ITNESSED 8Y TOTAL LEAG'H/NCi AREA 2 1°�S FT. T�PSp� ` - - ---. _ PERCOL.�►TIO/V RATE�/ Lis M/N?/I/1/Chf �r� Q /✓a �--O^ "`'I AENCOI-A77aH RATE Ik2 7-/-/,ll mim.//%VCH R.E5ERVE1-E4CHI)V6AREA 54. FT. ZM0 � l3C�tJ � o S a y 4•NO LB - v+ MORSE u, No 10951 O OREDGEENCHNEERING C0,1NG. ND SUS FSS/ONAI Ea6 _EG, 9, 3. 7/2 MAIN ST. , HYA"NiS, MAss. GO A'• NO GROfJN[7 YNi4TCR ENCOIJNTL�RE� /VT: �� . D►RTE: �/z�G ex./E Q G/40'UAID PVA7--R AT ELE(/., - .IOB ND.• Si o z3 z SHEET_0,w