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HomeMy WebLinkAbout0019 PADLOCK LANE - Health 19 Padlock Lane Centerville Q = 172 114 No. 4210 1/3 ORA Pendaflexo 10% No. CJ�� l 4 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for �Digogal bpgtem Cow5tructiou Permit Application for a Permit to Construct( . )Repair(l-l^pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. fy PA %pC k 44",-5 Owner's Name,Addres and Tel.No. cayrr,rV/1/% l4�;an� Assessor's Map/Parcel Installer's Name,Address,and Tel.No.508—`/1d 9:75$ Designer's Name,Address and Tel.No. ;78'/-3—B S�—O 2 q Jo�e,04 U,9OA-,-a:, IU.q .w, )01,6�y�x Type of Building: Dwelling No.of Bedrooms 3 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 Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �s�� Y- Te O(J low /= / �/ <r ko y' 9gy'OUv� 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 Boaz of H lth. Si ed Date Application Approved b Date Application Disapproved for the following reasons Permit No. a2ck3 (P Date Issued 11 O TOWN OF BARNSTABLE cc J.,QCATION 117 SEWAGE # LJ5 V,iLLAGE LE117''/_r411/lr ASSESSOR'S // MAP & LOT 172� INSTALLER'S NAME&PHONE NO. �D6 5 20—r1��a' �/0.5iZ1i Ui l3�vN�v� SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) ZV 500 &e:4/ C�Illw i=/ sizej ZSX /3 NO. OF BEDROOMS BUILDER OR OWNER jZ' i4k PERMITDATE: COMPLIANCE DATE: /L— 25 —03 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 Wedand and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �a� �N Jl 19e-p 0, l F W O a • 9,q, v ZL ��s s Ze el f y� -t? V, - . � r �'U� � � � ��''Sf©� �� �� /Ow °'i ��'`� � I __ C)C) ;i No. '' . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �. Yes r �A PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Mi.5pozar *p0em, Construction Permit Application for a Permit to Construct( . )Repair(4',Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. H Pi dlo c k Owner's Name,Addres and Tel.No. Assessor's Map/Parcel / Installer's Name,Address,and Tel.No.50Z—'Y20^ '7;7J E' Designer's Name,Address and Tel.No. c5l G-i4*r�r�xq..a Q ,,F,I i'..�r' I//,�tr�= „�Tr'/�=��7� 4i'c%YbU`r'� Type of Building: / Dwelling No.of Bedrooms ::3 Lot Size sq.ft. Garbage Grinder( ) Other T1 pe 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 Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) a f 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 Board.of Health. Si - ed � �' •.. -•—=�2.�.'G�-' Date Application Approved by t Date �� Application Disapproved for the following reasons ` Permit No. Date Issued I c� i i 0 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( �)-L.ipgraded( ) S{ Abandoned( )by 4), at f %G?/ / 1tri' i dui%= Yit/ has been constructed in a•cordance with the provisiaons of Title 5 and the for Disposal System Construction Permit No. pd dated Installer C} J 0 1yeV-vS U Designer �r,�� The issuance of this permit shall not be construed as a guarantee that the syst m will.function'as designedf:) Date I ,,Z 3 /0 Inspector t.. )A' /'j,! - 1 � � V� --------------------------------------- 3 P D No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( )Repair( )'Upgrade( )Abandon( ) System located at I q f 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 mu t be completed within three years of the datb�yv thi e Date: a ���6 D Approved Commonwealth of Massachusetts - - _ w Title 5 Official Int pection Form - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 19 Padlock Lane _5 Property Address ..... .... Dana Winroth Owner: Owner's Name information i e required for every. Centerville MA 02632 4/1.6/13 page. City/Town - . .... State Zip Code. Date of inspection 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: k.ey to move your cursor-do not... Matthew Gllfoy.. use the return. key. Name of Lnspector b. B& B Excavation;Inc. Company Name 14 Teaberry Lane Company Address Forestdale 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 ithat 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 4/16/13 - - Inspector's 5 nature f - - .. 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 systemmill perform in the future under - - the same or different conditions:of use. - - _.. . ....... .... . l/L V l5ins•11/10: Title 5 Official In ec_ n Form:Subsurface Sewage Disposal System•.Page 1 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 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 an information which indicates that an of the failure criteria described Y Y 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 page. City/Town 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 '/ day flow t5ins•11/10 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 5. 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 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•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspec ion Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ye 19 Padlock Lane Property Address:. Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 : page. Cltyrrown -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 ❑ Z 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 El Z this inspection? Were as built plans of the system:obtained and examined?(If they:were not El 0 available note as N/A) ® ❑ . Was the.facility or dwelling inspected for signs of sewage back up? Z El 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):- 3 DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 330 t5ins•11/10_._ Title 5 Official Inspection Form:subsurface Sewage Disposal System Page 6 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): n/a Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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-11/10 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 ;M 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 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: aeons 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 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: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'6"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order no sign of leakage or blockage. Septic Tank(locate on site plan): 1'3" 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 gal Sludge depth: no sludge t5ins•11/10 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 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour 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.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 page. Citylfown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 'L f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 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 0 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.): At time of inspection d-box appears to be in good condition. 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.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 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 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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 condition. No sign of hydraulic failure 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 page. City/Town 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 n incondition o d of ve vegetation, ( 9 Y p 9� 9 , etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 L Commonwealth of Massachusetts Ti#l=e 5 Official Inspection Form o Subsurface Sewage Disposal System form-Not for Voluntary Assessments 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is Centerville required for every MA 02632 4/16/13 page. Cityrrown State Zip Code Date of Inspection 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 0.drawing attached separately L-6 I O II'i 1 ® A'_ bI 3 A2_ i' a2-a3� O3' S� 0 Oft 4' g i t5ins•11/10 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 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 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: >133" 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: 7/5/03 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: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 19 Padlock Lane Property Address Dana Winroth Owner Owner's Name information is required for every Centerville MA 02632 4/16/13 page. City/Town 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 SIMPLY CLEAN CAPE COD LEGNA MONTEIRO _ House Cleaning Specialist (774)251-0275 — We-L-ov_e';RefiFraw- contact@simplycleancapecod.com " cle _. r contact@simplycleancapecod.com www.simplycleancapecod.com (774)251-0275 Residential-Commercial-Vacation Rentals A'. TOWN OF BARNSTABLE Date: TOXIC AND HAZARDOUS MATERIALS - NAME OFBUSINESS: Le� K5 G to&kjA r1 SQL U ICES 2`�G�-S?7Z'�T�D� BUSINESS LOCATION: S INVENTORY MAILING ADDRESS: ,I TOTAL AMOUNT: TELEPHONE NUMBER:( I Ga A5 CONTACT PERSON: _/�c'��11 I=. /rCvi�6teo EMERGENCY CONTACT T LEPHONE NUMBER: (51-ae)360"cd rtW 1� MSDS ON SITE? TYPE OF BUSINESS: Gf�f�,,yL(K SeI�UI��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 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 Imay be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers bleach) o removers&cleaning fluids (dry cleaners) Other cleaning solvents--JAB Bug and tarYen/ i §e Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials azardous Materials Inventory Sheet Checklist Date Physical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials-no blanks) Storage Information -location of storage, how long is storage for? If none, note that. /v Disposal Information -where and who? If none, note that. plicant Signature - understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and plain it Attach the Business Certificate with your sign off and comments. **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them 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.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) r DATE: f� p Fill in please:. APPLICANT'S YOUR NAME/S: �i'ryl tl'�{I'i�jz�i: ,1iN111i1�U..�i r' IeN r '-=t " r p BU INES YOUR HOME ADDRESS: �:u:.q.•'M fa4R dT I." - !t x'x,lte �;z''i�3.[fTs' r"n+17i�'S1fIEf;:i'o- �- `I '•Y����/�—� TELEPHONE # P �, .,�,����;;;•d,,.;,�. Home Tele hone Number I�'N qa.rgpFwp:r^ r I,:Nlffrl.llfKlt::''d:E;Yfif;77il'•:}' NAME OF CORPORATION:NAME OF NEW BUSINESS .� �i'��5 TYPE OF BUSINESS C vt IvI fX :Ub� A [ �+ IS THIS A HOME OCCUP ThON9 „ES NO ADDRESS OF BUSINESS MAP/PARCEL NUMBER (Assessing] v� ll � 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 Rai. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. TION 1. BUILDING COM SSIO ER'S OFFICE AEOCCUP MUST C®MP 1' \111T1H' OW 0 1S FAILURE�TO This individu I h p-i.gf r o an permit requirements that pertain to this type of bush t.ES AND REGULATt COMP' Rlgo -T1 51NES• �u ho ' e Sl -ure** COMMENT 6 - 2. BOARD OF EALTH This individual ha been info f the p rmit re rements that pertain to this type of business. . ** . MUST COMPLY WITH ALL Authorized ignature COMMENTS: HAZARDOUS MkTE,R1ALS RECULATJONS. 3. CONSUMER AFFAIRS [LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS; 1 • Date: ' TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE NAME OF BUSINESS: �/yY155eoe,U l'C�S 2`6G/.5�� °rT r �sI BUSINESS LOCATION: 5671to, INVENTORY MAILING ADDRESS: Piq&a oe >Qy►I >°-rm� n �3o2 TOTAL AMOUNT: TELEPHONE NUMBER:(- CONTACT PERSON: EMERGENCY CONTACT T LEPHONE NUMBER: 6 O63F-©dam -M(Acp MSDS ON SITE? TYPE OF BUSINESS: 611?f?''Vldb6 Se/2tll( 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 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 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 ay be toxic or hazardous (please list): 0 Metal polishes Laun ry soil &stain removers tKIKGrLding bleach Spof rerriovers &cleaning fluids (dry cleaners) Ot er cleaning � CYY�L Bug and tar rem r r 1 � Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials TOWN:OF BARNSTABLEL LOCATION SEWAGE # VILLAGE � �r/"` Ih ASSESSOR'S/ MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ( LEACHING FACILITY: (type) �-540 Gym rss� isl�fsize) :�rx 13 NO. OF BEDROOMS BUILDER OR'OWNER PERMITDATE: COMPLIANCE DATE: / '23 —49 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 Feet on site or within 200 feet of leaching facility) Edge of. Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by �f AssEssoRs MAP: {`12 TEST ` HOLE 1- OGS NOTES: � I I'� 1) THE INSTALLATION MUST BF, �N SUBSTANTIAL COMPLIANCE WITH PARCEL : r\ ER S. C. 7� THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF FLOOD ZONE: SOIL EVALUATOR : �. �Ey �� ;� l�ttl�( BOARD OF HEALTH REGULATIONS. V WITNESS : Nor w L �� REFERENCE: C. Uo 2-59 DATE: l7TU!7 7,ZX3 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, c PERCOLATION RATE:_ �'' SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO 0� I c ASS („ I19cfif _ o.� 9 pd INSTALLATION. S7 C J..SU!t 1 � - V / �TH- ( TH-2 �- �C7 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE DETERMINATION. S1 l u r l 7 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS CpAM i (� SPECIFIED OTHERWISE) S�r7� p, LOCATION MAP(NTS) /� 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A 3"1"� GARBAGE DISPOSAL. 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) 2•Sr/ ! MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON A BASE OF 6"OF CRUSHED STONE. 7) FXIS7 A- t� f+l N ti 133 C, (0 Z, f�'q-� 7!i �ae 1,E qv, ti.+�, E,�� cr._wl Cc�79,V��,✓�� - -_� w ove --- - �) 1�10 KNawN PPJVhrE. �JEu,S...tv��N.ISo_o�..Pi2U,PU5ED..G� r!J4,--_... SEPT I C `-:)Y S T EM DESIGN - FLOW ESTIMATE GIL 3BEDRO)MS AT IIO GAL/DAY/BEDROOM - 330 GAL/DAY SEPTIC TtNK J�CGAL/JAY x 2 DAYS GAL USE �7 GALLON SEPTIC TANK —A/tu.) �po°LS 60 SOIL ABSC'RPT I ON SYSTEM 5�a) P Fx,4sr- t,6" cl at I � � �1 .�,I� t�►J I�;ti�., �.1�� . �J �x i'� W X 2 b� _ Flu , S I VE AREA._U"2�) ( �� x ��L 4/IV' p i1 21 BOTTOM AREA 25 X 13 v Q �y — Zqo. so IJ� o C r SEPT I C : SYSTEM SECT I ON p I -i$M= T4•F. \ -To 0T- FfI Pry ° `- Mt 1 - -- p a %o„ Iq„ n sh��ndr tgr s►,rrl� ,c ; p f� Y � 0� T f y �p 1- J D SY� �," "t (p/ ASPS D-BOX GAL 6-8.v afr � I SEPT I C TANK i y' o0 Z BLIZ /IcceSS A �QTfGM of T�STHOa- L' �9•OL 06K , SITE AND SEWAGE PLAN LOCATION /1wLoclk- L4AIE ���ZH OF M CEN7 :PEVILLE , f�I R PREPARED FOR : sL�i�G� No. 1140 s'4N,TAR,PN DARREN M. MEYER, R.S. SCALE:/ =Z� fpyajy-T1w�1�D gy ; 0�7 DATE: 7:S-ems�-�� 43 VINE STREET ��pQ �I N (,D► � ,�,5 DUXBURY, MA 02332 W DATE HEALTH AGENT (781) 585-0293 3 W Z