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HomeMy WebLinkAbout0077 OLD POST ROAD (CENT.) - Health (2) 77 Old Post Road, Centerville =209 - 101 SAY IN UPC 12534 k° No.2� 5,��.c a. MASTINGO.MN Date: 1160 y TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: /V� BUSINESS LOCATION: ^7 7 D 1a �a.S+ V�l��C MAILING ADDRESS: Pa r2o X /5,8'S' Z- oZ 6o' Mail To: TELEPHONE NUMBER: 5� �- 2-c� fat, y Board of Health CONTACT PERSON: Town of Barnstable _e Le.� �^ ^^ P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: C Does your firm store any of the tox hazardous materials listed below, either for sale or for you own use? YES NO V This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. 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 41 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 Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor& furniture strippers hydrochloric acid, other acids) Metal polishes 2 Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Z Spot removers & cleaning fluids (dry cleaners) 2� Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS I / C —. V Fee C7 No. — - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippricatiou for Migpool *peum Com6truction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) El Complete System l� vidual Components Location Address or Lot No. �7"A,52-- Owner's Name,Address and Tel.No. Assessor's Map/Parcel G ee/r/,V I j/e. Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. 0-1-/Ge&517-` 771-E3$P Type of Building: 7 Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( ® Other Type of Building e5 Bye " No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ile gallons per day. Calculated daily flow 3J9 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank eX/&,,L/h,9 Type of S.A.S. /JX Z 15PXZ Description of Soil 3 Nature of Repairs or Alterations(Answer when applicable) 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 th' ar f Signed�_ Date Application Approved by T� Date I I -3eo -O/ � Application Disapproved for the ollowmg reasons Permit No. Q 7 - �� Date Issued ALI No. _ _ ? >, 3, Fee ✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mtgpo.5ar *pztem Con5truction -permit Application fora Permit to Construct( )Repair( )Upgrade(V)Abandon( ) ❑Complete System iI'Irtdividual Components Location Address or Lot No. t f Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. J Designer's Name,Address and Tel.No. ,�itaGo�i Coast"- 77/ �39 Type of Building: 2 Dwelling No.of Bedrooms J Lot Size sq.ft. , w Garbage Grinder( � Other Type of Building P_5/ elw e, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 33e:� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank leiWe w' C'X%57`/ r, Type of S.A.S. /l 2 7 e;KZ Description of Soil 3 ��✓.E�iIt1%2�/ S Nature of Repairs or Alterations(Answer when applicable) 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 th' Bear of Hea Signed % Date Application Approved by - Date /1 -Ari -C/ " Application Disapproved for the ollowing reasons Permit No.9,7 - �.3 9 Date Issued THE COMMONWEALTH OF MASSACHUSETTS �9�© f BARNSTABLE, MASSACHUSETTS 4, Certificate of Compliance THIS IS TO CEPTIFY,that jhe On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(✓) Abandoned( )by D D of 5 7`. at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - dated Installer Designer The issuance of this pe t shall Gn�ot be construed as a guarantee that the system will func ion as designed. Date --! T Inspector --------------------------------------- No. ZZ — -7, Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS . Mwizpoml 6potem Congtruction Permit D Permission is hereby granted to Construct( )Repair( )Upgrade(---')"Abandon( ) System located at -7 ©X0 - 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: Approved by�_ l r 1 9 f Y 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 7 , concerning the property located at 7 2 D/e�/���� � meets all of the following criteria: F/ There are no wetlands located within 100 feet of the proposed leaching facility. /There are no private wells within 150 feet of the proposed septic system ✓ ere is no increase in flow and/or change in use proposed There are no variances requested or needed. +z If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) �77- B)Observed Groundwater Table Elevation(according to Health Division well map) �© SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:halth folder.cert 1, l Ck i� -1 Z G ,-„) I i N i 4 i I � TOWN OF BARNSTABLE >:LOCAT'ION 7 7 e101 SEWAGE # 1 737 VLL AGE' G7` `//��fiP• ASSESSOR'S MAP&LOT y©! 1STALLER'S NAME&PHONE NO. BorlvlCo':�b�` �, -9399 .;: ,SEPTIC TANK CAPACITY �, /4 L , j EACHING FACILITY: (type) t�iw1i►J �,�e�—(size) f/ Iu9 ��Co? OF BEDROOMS-- 0 _ PERMITDATE: COMPLIANCE•DATE: Spparadon Distance Between the: :Maiunnum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Pi vate Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wettand-and Leaching Facility(If any.wetlands exist within.300 feet of leaching facility) q Feet shed by I TOWN OF BARNSTABLE LOCATION 7 7 ele SEWAGE # �'7`7314' VILLAGE G 7`rm7/d� ASSESSOR'S MAP & LOT 7—Of—Ap/ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY !,00d 44 L LEACHING FACIL=: Tw{��/p'Q a' � (size) �� ��l��I >60? � (type) NO.OF BEDROOMS 3Q BUILDER OR OWNER PERMITDATE: 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) /r°% Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 7�O i Lr q4' i i h 2'I 3G ,XI 7,4 sr�ric ?-4m%-" = 3.3� /�50 s�z�ew,a: AZS,4 = /5a S,— i /50 SF '.' ''Z'5 GPLD � 1 3 8 $D sF � 74)T,4L aR-S G,V e251 oU r.rr.Jc ZX/4 y o� OA,/ = 33© 4-PD Exn ram. l�Erzc J'�" 7" 1„,neVP ,N �-,�f✓ r - !`' 1? Sif �`F'•` TO' A"z zor q7 . . 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