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HomeMy WebLinkAbout0175 FIVE CORNERS ROAD - Health 175 Five Corners Road A= 168—070 Centerville S M E A D No.Z-10WR UPC 12M .nN.a.aom • me&In um 1 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 FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is may' required by law. DATE: Fill'n please: APPLICANT'S YOUR NAME/S: e e� at ,,� `'gin .;''" _sik BUSINESS YOUR HOME ADDRESS: ✓ TELEPHONE # Home Telep one Number NAME OF�CORPORATION: NA NAME OF el NEW BUSINES S _' ,-- TYPE OF BUSINESS 15 THIS A HOME OCCUPATIO --S -N d �� (Assessing) ADDRESS OF BUSINESS. P/PARCEL NUMBER / ( 9) 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 COM SION R'S OFFI MUST COMPLY WITH HOME OCCUPATION This individu ha b inform f an p mit eq 're- erits that pertain to this type of business.COMP AND AR RESULT)IN FINESS. !LURE TO Aut rize n ture'` /J OMMENTS. % (� 1IV U It kJO /1 . 2. BOARD OF H LTH This individual has been inform d of t permit requirements th ertain to is type of business. MUSY COMPLY WITH ALL Authorized Signature** AZA PODS MATERIALS REGULATIONS. COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Date.6-/--2X TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: 6weloA BUSINESS LOCATION: '7 - rS INVENTORY MAILING ADDRESS: VQ Q 7Z TOTAL AMOUNT: TELEPHONE NUMBER: R` 7'71n CONTACT PERSON: ro-r,Les, � )a e!e EMERGENCY CONTACT TELEPHON NUMBER: �S"�l.(D �k� MSDS ON SITE? TYPE OF BUSINESS: p� CQ- 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 material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts(Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (pleaseliist): Metal polishes no k ( � (cc, (a Laundry soil &stain removers tov (including bleach) < Spot removers &cleaning fluids (dry cleaners) 0-&rl A�� Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Appl' 4ii-go-elCre- Staff's Initials Commonwealth of Massachusetts 10 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments n' �M 175 Five Corners Road , Property Address �•ti7 Estate Of Frank McGuire Owner Owner's Name / t_. a1 information is t/ •: required for every Centerville Ma 02632 8-17-15 1— page. Cityrrown State Zip Code Date of Inspectiol eX. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: / key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. B&B Excavation ITV Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-17-15 In Ktture Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal y em•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City(rown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a 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 or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail: 2013-8,000gallon 2014-7,000gallon Sump pump? ❑ Yes ® No Last date of occupancy: July 2015 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: new overflow added 1994 to existing tank Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1,6„ Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 9" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order with liquid level equal with outlet invert. Tank is not in need of pumping at this time but outlet tee is missing and should be replaced. Grease Trap (locate on site plan): Depth below grade: 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,a 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 (6'x4') ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Pit was dry with no sigh of back up. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 City/Town/Town State Zip Code Date of a e. tY Inspection p9 D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference�landmarks or benchmarks. Locate.all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Fro4 A t3 0 O 0 B VI?_ T ci - is G3'} 3ca t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No Gw 10" 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: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Property in a higher elevation You must describe how you established the high ground water elevation: USGS TOPO maps Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 175 Five Corners Road Property Address Estate Of Frank McGuire Owner Owner's Name information is required for every Centerville Ma 02632 8-17-15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 EXISr17JC7 _ )75 rivECorv%crzS aawD,C�N"rr-mvi�It,d�l 'D 4a" 14 • 4 4 "5e 4�rr ira n a � i v ®. 0 t� S0 GAR � i Li �. VL 4 L„o � q.Q„ o o . ,r" r1 4 fh. C N d V r ClOS 121.J No.. ...... APPROVED THE COMMONWEALTH OF MASSACHUSETTS am ble Conserve' BOARD OF HEALTH A.1, �J ' OWN OF BARNSTABLEUS' s , pphratiun for Divi-puittl Work,i Ton,itrnr#iun ramit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at -----------------------------------•------•------- ��]� •.Location.................................................-Address ....or Lot No. ____...•..---.....--^s................... ner_!5 & �L�V ! fU ._ � .............................. .__ Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.__-------------------------------Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' 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. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- ----------------••----------------------•----•-••-------••--_.... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit-------------------- Depth to ground water__._-._._-._____--____ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ODescription of Soil---..._1 19 ...........................................................................................----------------------------------••-•---------- x w •------------•-----------------------------------•-------•-----------------------------------------------------------•-•••_••----......---•-----...-•---••-----••-•---••-•--•----••--••......-•-•-•. x -----•-------------•----•--------------------------------------------------------...-------------------------------------------------•-•••. ------------- U Natur of Repair or Alterations—Answer when applicable_. -%r0l7f_% 9L/----_ 1� __________________ • ---•----------------------•---------.....-----------------------•-----••--------.....---------------------------------------....---------------------------•-•---__-•-- 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 bee issued by the r health. Signed .���.... --------- ----- ----- -------------------------- ---- .. ---.1.... fDace Application Approved By -------------------- --- ' 1 ... .......................... ....-- D---- ----- Application Disapproved for the following reasons: ...................... .............. .......... . ... . ......................................... . . . .... ------ ----------------------------------------------------- ----------------------------------------------------------------------------------------------------------- .........------- - ---------------- Permit No. ...::. . oe - _ --------... Issued - ------"` " Dace No.. .............",- Fps :.. ..- ��e THE COMMONWEALTH OF MASSACHUSETTS -7 V BOARD OF HEALTH /G La (� �IrOWN OF BARNSTABLE 670 Appliration for Ubvi-p ial Workii Toiigtrurtion Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .� 7` �iv .._ '�r e�,51� 'e�27rv�flees------ ------- ---------- - Location-Address or Lot No. arcc��r - ----------------------------------- --------------------------------------------- ----- .`.t.4.6.../_.1-�/JI�J��ner //� .. PD, .............................. . . �.... Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms---______________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------------------------------------------------------------------- ------------------------------------------------•-•--.--.---- 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. Seepage Pit No--------------_----- Diameter.-._--_-_-...__----- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................... ...................................... Date........................................ Test Pit No. 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........................ tx c-- ------------------------------•--------------------------------------------------------------•------------------ --------------------- •...... --------•--- D Description of Soil........ -------------------------------------------------------------- U ----•-••-•-•-•-•-------••-••-------•--•--------•......•----------•-•---•--•-•-••----•--•••---••-----••---•----•----------------------------•---••---...•--•------•--•--•-•-••••--------...-•-•----.-•--- W •.............'---------------------------------------•---------•--•------•------------••-•-------------------------------- --------= f---- -- U Nature of Repairs or Alterations—Answer when applicable._f�'.Q�,;074 1..___-�ve 4�.................. ..•........ a-- -------------------------------------------------- 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 bee issued by the r Lhealth. fi Signed ..... .. .... .'...:L Dace Application Approved BY -------!' ........�./1��'1. ... .................... -- t jDace Application Disapproved for the following reasons: ................... . ... . .... ......... . ..................... ........................ ...... . . ................... . . .... ...-................................................ ..................................... ---------------------------------------- Permit No. ----- 6------ - '------------- kIssued ........... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Gertifirate of To nylianre T11 IS T CF�RTIFY, That t -e Individual Sewage Disposal System constructed ( ) or Repaired�(�) y I,t/ . � / �dl/2Saj ----... �i. - at ..�_..L..../.... ....�.../.v. ... OY./�>°r ie,:ne.. ��..L-L�/'�//.// .... - has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. �'..��,_._-_.�.�._,�...... dated -.�,,,�-•_.j_.�,,'�-�..�� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------- /� /'... .. ._.....___..... .. Inspecto :... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No....................... 45' FL 6/O �iopo�ttl rk �•oit�tr .ton rr�t�tt - 11� ��. �.. Permission is hereby granted_!✓_____ __ �._...�f?S�f�..____s ._ �...._._.._....__ ' to Construct ( or Repai Oan IndividutSewage Di. osall System Ile— at No.)-7 �l__1._[J �rC1.`P.�'�5 !.�.-V--•--. ---!i�c�-!':!J/- .2.----------------------------------------•----......--- st C-9�t / as shown on the application for Disposal Works Construction Perng ''_. �� Dated.....-------------- .. �•,•. / �jr,., � �� Board of Health l DATE........... / FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LOCATION r'v ��� 2-S' SEWAGE VILLAGECE,t,,77A VIG1� ASSESSOR'S MAP & LOToif 6%0 INSTALLER'S NAME & PHONE NO.Gy ®�j�jt/SD x� 7s F7761 S'PTIC TANK CAPACITY a4:> LEACHING FACILITY:(type) c,4 5"T (size) X NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERPO b/c BUILDER OR O WNERJXJV419'f "�q DATE PERMIT ISSUED: ` /�� DATE COMPLIANCE ISSUED: �'l Cai VARIANCE GRANTED: Yes No �/ ���� l�� a �� � . �- �; � �� `� �� � ,, lac iSG'�� �l� TOWN OF B.ARNSTABLE � �87 0 ,ev LOCATION Je Coy.icr 5 (�� SEWAGE # VILLAGE �`'`l�L ASSESSOR'S MAP & LOT 16c 9-0ti© INSTALLER'S NAME & PHONE NO. C 1 OPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) N . OF BEDROOMSPRIVATE WELL OR PUBLIC WATER i BUILDER OR OWNERG DATE PERMIT ISSUED: DATE .COZIPLIANCE ISSUED: VA NC­�k- NT D VAa- No �j2 Al t,->4k_,' e-� P'J,, o�sF G-�P���� i � � 1oi ,� Fro UT'ya Raj � � *�S � � i _ , o � ,� "�' ��i I