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HomeMy WebLinkAbout0042 NYES NECK ROAD EAST - Health 42 Nyes Neck Road Centerville A = 233 024 0 t d 1�t Y f 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 required by law. DATE: I I )b X Fill in please: ,r r il APPLICANT'S YOUR NAME/S: 4- BUSINESS YOUR HOME ADDRESS: LC1 q.G Ca L,C eS lti'�� I Cam-` 1a(G C l L1 l'. C TELEPHONE # Home Telephone Number NAME OF CORPORATION e� NAME`OF NEW BUSINESS' TYPE OF.'BUS.I,NESS ('J. ' )-2�i IS THIS°,A HOME OCGUPATION9 1V:" YES NO ADDRESS OF`BUSINESS r l MAP/PARCEL NUMBER 3 (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 COMMISSIONER'S OFFICE MUST COMPLY WITH HOME OCCUPATION This individual has e'n info d a y p mit requir ments that pertain to th4q�LPP�gfA%!P ,.S. t)LATIONS. FAILURE TO Au oTized Sig atu - ** :COMPLY MAY RESULT IN FINE. COMMENTS:(Id — ___ 2. BOARD OF HEATH MUST COMPLY WITH ALL This individual has bee n ad of the permit requirements that pertain to this type of business. Y HAZARDOUS MATERIALS REGULATIONS Authorized Signature* 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: i / �© y TOWN OF BARNSTABLE Date�� /�) TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: BUSINESS LOCATION: - K e.. L' �VI� �e Ili INVENTORY MAILING ADDRESS: ,j( p� L1 , �n`�-er 1)i GIB_ „ t`��ZG,�TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE UMBER: - MSDS ON SITE? TYPE OF BUSINESS: INFORMATION / RECOMMENDA NS: 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 re uires 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 T Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) -•'� ,�� e, (0 Y-!a C -�i C p r Spot removers&cleaning fluids _ (dry cleaners) /� al t-l.cell- 3QA-e-a n el S �(.1j/y Other cleaning solvents Bug and tar removers V!Y) a.f 1--:eYYt 0 Windshield washA.. WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials 1%4 \ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED i FEB 2 4 2004 TO'.,N E - f • TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A MAP CERTIFICATION ---- , ii'' _ PARCEL, ; 1 Z Property Address 7- 05 ��K-- East LOT Owner's Name: c t,C� C'�t"�P rl Owner's Address: Date of Inspection: Q'L_ 5 (7 W Name of Inspector:( ea e print) �f Company Name- Mailing Address: r' Telephone Number: Jl 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: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: , Date: — -0 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 systern or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address flow 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 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: `�'L t�v k 'c k--i')_ ey� i'Y Vt rt' Owner: Date of Inspection: C)'�- 0 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 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: L- ocPD Cn.>�� B. System Conditionally Passes: N One-or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The''system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal'and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiI"tion 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 6�high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or unevei-distribution box.System will pass inspection if(with ' approval of Board of Health): �. broke»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: "Page 3 of 11 g , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A AA CERTIFICATION(continued) 0 C_ Property Address: Z A A�c, XCC . R CAS+ Owner: PG �( i� C 'L Date of Inspection: 2 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 failin o protect public health,safety or the environment. / 1. Syste will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(1y)that the system r not functioning in a manner which will protect public health,safety and the environment: Cesspoo or privy is within 50 feet of a surface water . _ Cesspool o rivy is within 50 feet of a bordering vegetated wetland or a salt marsw J - 2. System will fail unless the B rd of Health(and Public Water Sup ier,if any)determines that the, system is functioning in a manner t t protects the public health,sa ty and environment: _ The system has a septic tank and oil absorption system(S S)and the SAS,is within 100 feet of a surface water supply or tributary to a s ace water supply. _ The system has a septic tank and SAS d the SA s within a Zone 1 of a public water supply., The system has a septic tank and SAS and AS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS d the S is less than 100 feet but 50 feet or more from a private water supply well". Method use o determin distance "This system passes if the well w r analysis,performe at a DEP certified laboratory, for coliform bacteria and volatile organic co unds indicates that the 11 is free from pollution from that facility and the presence of ammonia nitro en and nitrate nitrogen is equa o or less than 5 ppm,provided that no other failure criteria are triggere A copy of the analysis must be atta ed to this form. 3. Other: r 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: `{Z CA\1eS �1 c� d• �=GS Owner: 1'- C it-c— Date of Inspection: '2 0� D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No jdt 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 �J 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than '/.day flow JQ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ATE Any portion of the SAS,cesspool or privy is below high ground water elevation. n1� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. v� Any portion of a cesspool or privy is within a Zone I of a public well. VQ Any portion of a cesspool or privy is within 50 feet of a private water supply well. j0 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.) hf'v (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 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. You must indicate- either"yes"or"no"to each of the following- (The following crt 'a apply to large systems in addition to the criteria above) yes no the system is within 400 of a surface drinking water supply i` the system is within 200 feet of a tri to a surface drinking water supply the system is located in a nitrogen sensiti ea terim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply we I%' If you have answered"yes"to estion in Section E the system is cons ed a significant threat,or answered "'yes"in Section D above the an ge system has failed.The owner or operator of an rge system considered a significant threat under Section E or failed under Section D shall upgrade the system in ordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: C aCr . CGS+ Owner. Date of Inspection: 0`1 Check if the following have been done You must indicate`yes"or"no"as to each of the following: Yes No t16_ Pumping information was provided by the owner,occupant,or Board of Health T—_ 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? 4)V Have large volumes of water been introduced to the system recently or as part of this inspection? T _ 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? _ O 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 bf the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Vain�e—nance Was the facility owner(and occupants if different from owner)provided with information on the proper 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. ,S _ 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)] S Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM(( INFORMATION Property Address: eS L d Evt Owner: C_f—" i c_ CR_e- ,1 Date of Inspection: D FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): .� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 2 Does residence have a garbage grinder(yes or no):f.VO Is laundry on a separate sewage system(yes or no):71_0 [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):A 0 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):&& Ado Last date of occupancy:7&:n� C MMERCIAL/INDUSTRIAL Type establishment: Design flo based on 310 CMR 15.203): gpd - Basis of design seats/persons/sgft,etc.): Grease trap present(yes o _ Industrial waste holding tank pr t(yes _ Non-sanitary waste discharged t r s stem(yes or no):— Water meter readings i able: Last date of ancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ri� Was system pumped as part of the inspection(yes or no):,l! If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM t/Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): IPage7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �r SYSTEM INFORMATION(continued) 1V� Property Address:H'L k NICE &= f _l Owner: lj ,t('Gl (2e Date of Inspection: BUILDING SEWER(locate on site plan) Depth below'gr-ade. Materials of construciion:�_._ cast iron 40 PVC-other(explain): Distance from private water su' 1 or'suction line: Comments(on condit' n join ntmg,`vidence.of leakage,etc.): r 1 ' SEPTIC TANK: (locate on site plan) Depth below grade: Y cj e— Material of construction:_„Cconcrete 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: ([) y- (n Sludge depth: I Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: pne- Distance from top of scum to top of outlet tee or baffle:_0 Distance from bottom of scum to bottom of outlet tee or ffle: How were dimensions determined: �'i►� 3'\A­ IP, Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural-integrity,liquid levels as related to outlet invert,f vide ce of leakage et 'c. �.xC�1er.� ,n� GIZEASE TRAP:_(locate on site plan) Depth below--grade: Material of cons tru n:_concrete metal_fiberglass__polyethylerieJ other (explain): Dimensions: Scum thickness: Distance from top of scum to top of o e or bafll` Distance from bottom of scum t ottom of outlet tee or b'affle:_ Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle con&tiet�structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM PUO��YS�M INSPECTION FORM ASSESSMENTS SUBSURFACE SEWAGE PART C SYSTEM INFORMATION(continued) Property Address: 2- J� � � Rd- }=G$ s-t r�^ Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) _ Depth below grade:_' �.•;., Material of construction: c_oncrete metal fiberglass_polyethylene i" er(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): ' in Alarm level: Alarm working order(yes or no): Date of last pumping: Comments(conditio oYalarm and float switches,etc.): I DISTRIBUTION BOX:K(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.): r S I r PUMP CHAMBER.-'jd7(locate on site C plan) Pumps in working order(yes or no):*j- Alarms in working order(yes or no): Cj Comments(note condition of pump chamber,condition f pumps and appurtenances,etc.): t R Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t� SYSTEM INFORMATION(continued) Property Address: q 7- �V clt �V �L R .. s� Lf� C►`��l� � L Owner: PUr,,"r 'eeYl Date of Inspection:--O-,L-7 6 q SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,.excavation not required) If SAS not located explain why: Type leaching pits,number:_/_ &ILI 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.): 1 _ t_eC'L' 1 i G�EGG��r+ v c 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 or no): 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: r 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: Owner: c�(-i c! fee-n Date of Inspection: 0 Z- Oq 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. 10, i yet 10 b Page I I of]] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: LIT Nr e'S Npc� rlGS� Owner: G1G� (e2�1C, Date of Inspection: 0 D SITE EXAM Slope Surface water Check cellar Shallow wells ` 1 Estimated depth to ground water /y feet N ���+A �� S �N `L 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: Checked with local excavators,installers-�ttach documentation) Accessed USGS database-explain: 1A> ;2=q,7 0 Lk-e G You must describe how you established the high ground water elevation: i _'�� 0 O O O L_cC,o,-r-c Q- 1�'`- C1 ``fe�� ��-�vN� -15 0 0 0 0 1 w 000 I, /Q J fi Aboue_ 3 ";-Oa- ��0 _ '� ---- ---No.��� Fee— =--------- BOARD OF HEALTH TOWN OF BARNSTABLE Z.pplicat ion-for V ell Con!5truct ion Permit Application is hereby made for Ia permitjto o struct ), Alter ( ), or Repair (fin individual Well at: loves t'je-1 Location — Address Assessors Map and Parcel A.2 If Owner Address n fox 4?4�0 Kk CA ------------- Installer — Driller -- Address Type of Building Dwelling --- -- - —- -- Other - Type of Building-- ------ No. of Persons--- --------____. T e of Well 'D — Ca acit Purpose of Well •0QAACzf;c- -.L"�� Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certifica a of ompliance has been issued by the Board of Health. Signed — _— - date Application Approved By ----- --- date Application Disapproved for the following reasons: — ----- ------ -- —_-- — —-- date Permit --_ Permit No. - -- Issued -- ----- date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif icate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired Y--- - - ------------------------------------ -_-__--_------- Installer at --- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ---- ---Dated----- ----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-- - Inspector---- - ------ - —------ 00� a No. Fee- -------------- BOARD.OF HEALTH TOWN OF BARNSTABLE A Application fforVeri Con5truct ion Permit Application is hereby made for a pernig to�Co:Wtruct,( ), Alter ( ), or Repair ( fin individual Well at: P — — Location — Address Assessors Map and Parcel Owner Address/ Q _ C u +�ti�ff l L `0 u— -- ✓°o �ah Installer — Driller Address ' Type of Building Dwelling --- -- ——---- ' Other - Type of Building-------- ----.---- No. of Persons-- ------------------____ --- Type of Well Capacity Purpose of Well OQ r ;c ' Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place�the-well in operation until a Certifica a .of ompliance has been issued by the Board of Health. ` Signed c^ '" --- — S J3 of -- ., date . Application Approved By ------- date Application Disapproved for the following reasons: . - � — --- --- —2VLA -- - ----_4n� date P Issued ------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( y' Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection f�' Regulation as described in the application for Well Construction Permit No. --- ----Dated----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. "- DATE---- -- - -- Inspector----- - -___ -=----- - -- BOARD OF HEALTH �d TOWN OF BARN TABLE s well Cootruction*rntit No.W-q0 A— Fee 1-7 Permission is hereby granted S(Q n 1' ^ �� to Construct ( ), Alter ( ), or Repair an Individual Wellat: 8 Street as sho M on Wha plication Well Construction Permit No.- Dated ---------------- ---------------------- DATE i Board of Health � ---� _—. `/ .0 No.- �s�U Fms.�...3 0. 0.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apptiration for Uhiposal lgarkii Tnnitrur#ion rautit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: 42 Nves__.Neck Road Centerville ........... ...._..._.. .. ------------------------------•-------------------•---•-•••-•-----.........._........_----•-----•- Location-Address or Lot No. Patricia ...eene... ................................. W J.P.Macomber Jr. Owner Address ,a .......-- ........ Instal ler Address UType of Building Size Lot...........................S q. feet DwellingX—No. of Bedrooms............ ...•..•.......................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) PaOther fixtures -.................................................................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ W 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........................................ a a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......-................. O p Sand---&---Gravel------------- •-••-•-••------•-------------------------•--•--._...-----•-------_----......-_-••---•--_---•------•--•--._...----------•----••-•-•-------••----- ..-• �_ Description of Soil. ........................................................ -•----...-•-.....------.......•-•.........--------•-- x U •-•••-•-•--•--......................................................................................................................................................................................... W ----------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable______________________________________•----•-_ _ _. _.-. -.____._._._....._. ._.. 1-1000 gallon tank 1-pump chamber 1-1000 ._;Leaching pit,.LightU1:arm 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 Complia ce has be iued y the boar of h lth. Signed ... 6�8�90 ....-------4--------- -----' - - --.......`-----.. -----I-------......--- ------...............------------------ te Application Approved By .......................................... ---------.. ... 1�..` �17-------- e Application Disapproved for the following reasons- ----------------------------------------------------------------- ----------------------------------- ------ ---------- ----------------------------------------------------------- --- --- --------------------- -- ----------------------------------------------------------- ------- -- ----------------------- .............................---------- /�JD oX/ - Dace Permit No. ....---/--- ---- ---- --/-/- ---- ---- --------- -----.. Issued Date _f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN-OF BARNSTABLE Appliration for Disposal Iforks Tonsirurtion 1hrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: .4 Ny P_B N r k...Road...C e in t e-ra;I l le-------- ---- ---------•--------------......................--------•--•------...............---------.......... Location-Address I/ or Lot No. ...................................................... ..........--.................................-----. ------------------------------------------- Owner Address w J E.MacAmbex Jr. -•...................••.•-_._e5i...... '"�z: a --•f---------------------------------• ,...,.-.........--•- Installer Address d Type of Building Size Lot............................Sq. feet V Dwellin �No. of Bedrooms............?............:.................Ex Expansion Attic Garbage Grinder g-� P ( ) g ( ' ) 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 ( ) aPercolation 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.............._......... P4 ----••---•••-------•--------••-•-•••••••----•-•--•••--•..........••---•................•----•••-.......................................... •.................. 0 Description of Soil...........$ad d..&..GraVey:..........-•--•-...-•-•-----••--•-••--•-•-----•----...-----•••---••....••--•--•••-••-••••............•................ W V ...•-•••-••••--•--•--•-•--••-••-•-•---•-----•----•---•-•••-•-•----•---•.............••---•--•-•-•-••--••••-••-•-••-••-••............--••••...•-•••---•--......••--•-•••--.......-•--•-••-•••••---------- W -------------------------------------------------------------------------------------------------------•--•----------------------------.............................................................. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .._1-1QOQ___aallon___tank_1-Dumta..chamber.._IQQ0. � aching pit,Light&Alarml 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 undersig-need fur herlagrees not to place the system in operation until a Certificate of Compliance has bee�sued by the boar of he lth. (!� . .. � Signed -........� .✓. .a ��,!! --- . �--./90 /� /7 Dare Application Approved By . 1 J/ i L,Q d/ -. .. - ----__.. ... „L Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------- ------------------------------ ---- --------------------------------------------------------------------------------------------------------------------------- .------------------------.....-----...------------------.---------------- ........................................ Dace PermitNo. ...- ��1-------------------------------------- Issued .................................................. Date THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH TOWN OF BARNSTABLE -�, (gertifirate of Coz>< plinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (KXD5. by.........J.._P..Macomber Jr. ------------------------------------------------------------------------------........... ------------------------------------------------------------- Installer at .........42--Nye s---Ne k----Eoa-d....Ge n t P rmi-l 1p.--------------------- ------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code s described in the application for Disposal Works Construction Permit No. ..A --_�76, ...................n. datede�� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED�AS A GUAR�ATE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. r Inspector ...21-- f f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE o.00 Disposal Yorks Tons#radion "permit Permission is hereby granted----_s ............................................................................................. to Construct ( ) or Repair (X) an Individual Sewage Disposal System atNo.42..5,1unn--- CentPrmi-.11e......................................................................................................... Street as shown on the application for Disposal Works Construction Permit No.. Dated... W. /� Q. .................. e..,.f..._� Board of Heath DATE.._.�..--�-�-------•--------------------------------------•---..... FORM 38508'HOBBS 6 WARREN,INC..PUBLISHERS TOWN OFvc/ , - LOCATIONTABLE a,-tL SEWAGE#_ VILLAGE C�n�,� ,i1�� ASSESSOR'S MAP & LOT _ 1 INSTALLER'S NAME & PHONE NO. L)_ SEPTIC TANK CAPACITY LEACHING FACILITY.:(type) � � (size) I GGG4l NO. OF BEDROOMS_PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER MAL& G DATE PERMIT ISSUED: FDATE 7 COUPLIANCE ISSUED: o ARIANCE GRANTED:. Yes No �� � 33, 0 p;T