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HomeMy WebLinkAbout0035 PEEP TOAD ROAD - Health 35 PEEP TOAD RD. CENTERVILLE A = 173 065 ' UPC 12534 No.2 153 ORq,o� HASTINGS,MN YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS NAME in town (which you must do by M.G.L.= it does lot give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 15t FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by'law. Fill in please: Date: - - s APPLICANT'S NAME: WN C F--. kW'Fos YOUR HOME ADDRESS: #` 1 - e In BUSINESS TELEPHONE # pg y g Q (p�I HOME TELELPHONE #: `77�/ o't$S� a�a NAME OF CORPORATION: NAME OF NEW BUSINESS VnAC Jan eC TYPE OF BUSINESS ��Ome *- Lt IS THIS A HOME OCCUPATION? -" _YES NO ADDRESS OF BUSINESS �� 1C� l I��4� Ce�► MAP/PARCEL NUMBER 01 L5�C, (Assessing) When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of Barnstable. This form is 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 town. 1. BUILDING COMMISSIONER'S OFFICE This individual has beeia inform gof any permit requirements.that pertain to this type of business. . MUST COMPLY WITH HOME OCCUPATION horized SignaturaP RULES AND REGULATIONS. FAILURE TO COMMENTS: COWPLY MAY RESULT IN FIN 2. BOARD OF HEALTH This individual hVeV infor ed of�ij�rer it requ' nts that pertain to this type of business. Authorized Signature** COMMENTS: HAZARDOUS MATERKS REGULATIONS 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature" COMMENTS: re y � / � / Q TOWN OF BARNSTABLE Date: g TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: INVENTORY MAILING ADDRESS: ID C1 TOTAL OUNT- TELEPHONE NUMBER: _ CD CONTACT PERSON: EMERGENCY CONTA TTELEP ONE NUMBER:—,,: UMBER: MSDS ON SITE? TYPE OF BUSINESS:' INFORMATION/RECOMMENDATIONS: Fire District: M 4 - yo! f urw Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum O erved/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint& varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor & furniture strippers Other products not listed which you feel Metal polishes may be toxic or ardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS i CO:�iMON\NTAI.TH OF MASSACHUSETTS EXECUTIVE OFFICE OF EIN-VIRO\biENTAI AFFAIRS = DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE n'I\TER STREET. BOSTON h1A 0210S i6170 292-550o TRUDY COXE Secretan- ARGEO PAUL CELLUCCI DAVID B. STR'.:HS Governor Comnuss:oner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:3 5 Peep Toad Rd. , Name of Owner G e orge Knight Centerville , MA AddressofOwner: 14 Mt . Plea*E_ant Square , Randolph Date of Inspection: �" - Q MA 02368 Name of Inspector:(Please Primt)Wm. E . Robinson Sr. I am a DEP approved system!inspector rsuarrt to Section 15.340 of Title 5(310 CMR 15.000) �nyN�: Wm. E . Robinson eptic Service Mailing Address: PO Box 1089, Centerville , _MA Telephone Number: 7 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-sitezasses disposal systems. The system: Conditionally Passes Needs Further Evaluation By the Local Approvinc•Authority _ Fails j Inspector's Signature: L Date: Iv The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS 4 t1� 1? revised 9/2/98 Pagel of11 n ►.. �rnied on Recycled Paper , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 'ropwWAddress: 35 Peep Toad Rd. , Centerville , MA %)wrwr: George Knight Date Date of Inspection: 7-11— L INSPECTION SUMMARY: Check A, B, C, Or D: A. J�SYSTEM PASSES: I have not found any information which indicates that arty of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SY TEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon ompletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate ye , no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipelsl. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed �4 revised 9/2/98 Page 2of11 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddress35 Peep„Toad. Rd., Centerville, MA Owner: Georg: n�grht Date of Inspection — I C. RTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the ublic health, safety and the environment. 1) S STEM 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone i of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OT ER revised 9/2/98 Page 3of11 F i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A " CERTIFICATION fcontinued) Prop"Ad&ess: 35 Peep Toad Rd. , Centerville , MA Owner: George Kni&ht Date of Inspection: fJ,13-� a D. SYS FAILS:/ You must i dicate either "Yes" or "No" to each of the following: I ve determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this de rmination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility-or system component due to an 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 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: he following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The own r or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of he Department for further information. L revised 9/2/98 Pagc4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART R CHECKLIST Prop"Address: 35 Peep Toad Rd. , Centerville , MA Owrw- Ge2rg Knight Date of Inspection: T Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and•the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ' / _ As built plans have been obtained and examined. Note if they are not available with N/A. V _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. v _ All system components, excluding the Soil Absorption System, have been located on the site. V _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: I _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)l The facility owner(and occupants,if differeru from owner) were provided with information on the propermaintenaaca of SubSurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'rop"Address: 35 Peep Toad Rd. , Centerville , MA Owner: George Knight Date of Inspection: '�� FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroo Number of bedrooms(design(: Number of bedrooms(actuaU�� Total DESIGN flow 4, p Number of current residents: Garbage grinder(yes or no):� Laundry(separate system) (yes or no)/� If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):_S 1998 61 ,000 Gal Water meter readings, if available (last two year's usage(gpd): Sump Pump(yes or no):" 1997 56, 000 gal. Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of a ablishment: Design flo qpd 1 Based on 15.2031 Basis of d sign flow Grease tr p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-san' ary waste discharged to the Title 5 system: (yes or no)_ Water eter readings,if available: Last d to of occupancy: OTHE tie Last a of occupancy: GENERAL INFORMATION PUMPING RECOR,S and,source of information: System 116mped as part of inspection: (yes or no) If yes, volume pumped: 6 gallons Reason for pumping: _ y�-��;� TYPE OF STEM 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: _�jr� !/c/ S 10--S -2 ey Sewage odors detected when arriving at the site:ayes or no) revised 9/2/98 Page 6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 3 PART C SYSTEM INFORMATION(continued) 'rop"Address: 35 Peep Toad Rd. , Centerville, PJA Owner: George Kni ht Date of Inspection: BUIL ING SEWER: (Locat on site plan) DeptJ low grade:_ Mateof construction:_cast iron_40 PVC_ other(explain) Distafrom private water supply well or suction line DiamComts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: , (locate on site plan) Depth below grade:, Material of construction:_'Xconcrate_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth:_ �,i Distance from top o�ludge to bottom of outlet tee or baffler Scum thickness: i + Distance from top of scum to top of outlet tee or baffle: ` I't Distance from bottom of scum to bottom outlet tee or baffle: L How dimensions were determined: ` rB ;omments: (recommendation for pumping, condition of inlet and outlet -ees or affles,�ep h of liquid��el in relation outle�invert, structural integrity, evidence of I akage, etc 1 O I'7 `� J / ��" / P h GRE , E TRAP: (locate site plan) Depth belo grade:_ Material of onstruction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions Scum thick ass: Distance fr m top of scum to top of outlet tee or baffle: Distance fr•m bottom of scum to bottom of outlet tee or baffle: Date of la pumping: Commen s: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidenc of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 35 Peep Toad. Rd. , Centerville , MA Owner: George Knight Date of Inspection: ?-43 7 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate site plan) Depth b low grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain) Dimen or Capac' y: gallons Desig flow: gallons/day Alar present Alar level: Alarm in working order: Yes_ No Dat of previous pumping: Co ants: (con tion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_v (locate on site plan) Depth of liquid level above outlet invert:_y� Comments: (note if level and distribution is equal, evide o solids carr er, ideas a of leakage into or out of box, etc.) - �.� 74 , PUMP C MBER:_ (locate on site plan) Pumps in orking order: (Yes or No) Alarms in vorking order(Yes or No) Comment (note condition of pump chamber, condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8oftl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 35 Peep Toad. Rd.. , Centerville , MA Owner: Geor�;e Knight Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number:::?-- leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Altemative system: Name of Technology: Comments: (note condition gtsoi, signs of by ra c failure, level of ponding dart�b soil, condition of vegetation, etc.) V ' V Y CESS OLS:_ (locate site plan) Number a d configuration: Depth-top f liquid to inlet invert: Depth of so ids layer: Depth of sc m layer: Dimensions f cesspool: Materials of onstruction: Indication of groundwater: infl w (cesspool must be pumped as part of inspection) Comments: (note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of nstruction: Dimensions: Depth of soh s: Comments: (note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r � revised 9/2;9c Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corr6rwed) Nop"Address: 35 Peep Toad Rd.. , Centerville , MA ° Jwner: George Kni ht Jate of Inspection: 13m 9 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate.all wells within 100' (Locate where-public water supply comes into house) r3 3 U revised 9/2/98 Page 10oftl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icorttinued) rop"Address: 35 Peep Toad. Rd. , Centerville , MA Owner: George Knight Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater AL Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions !/Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) )36 �Y 6,6 G revised 9/2/98 Page tlof11 l TOWN OF BARNSTABLE V LOCATION bar SEWAGE # 7 VILLAGE , - r ASSESSOR'S MAP & LOT — 25 INSTALLER'S NAME&PHONE NO. !3a SEPTIC TANK CAPACITY A 0-6 LEACHING FAciLrrY: (type) aZ, O,I d S d"� `- (size) l ol- ice"2� I NO.OF BEDROOMS 3 BUILDER OR OWNER T rrs 'r� PERMTTDATE: S°- `` COMPLIANCE DATE:--;?— Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leachi ' acility Feet Private Water Supply Well and Leaching Facility (If any is exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any well s exist within 300 feet of leaching facility) Feet Furnished by L t I � t TOWN OF BARNSTABLE LOCATION isv ram/ SEWAGE # VII LAGE_� -,. _ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /6 ©—O LEACHING FACILITY: (type) . ,s-/. — i,�+ C. (size) 5. NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: L —a COMPLIANCE DATE: ;�'/3v Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leac2sgex�ist .- cility Feet Private Water Supply Well and Leaching Facility (If any on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetl s exist within 300 feet of leaching facility) Feet Furnished by r 7 e/ No. Fee$50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppricatton for Ztgogar *pwm (fongtruction Vertnit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ati Addres r Lot o wner's Name ddress Tel.No. VeepoadN Rd. , Centerville, MA �eorge �nigi' Assessor's 7a 14 Mt . Pleasant Square , Randolph, DIA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E . Robinson Septic Service PO Box 1089, Centerville , MA 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 S and. Nature of Repairs or Alterations(Answer when applicable) New Title-5 leach system. Heavv d.utv D-box and. 2 Heavy duty leach chambers . 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 y t is B and of Healt `- G Signed ��; ,o Date � Application Approved by Date Application Disapproved for thgfollowi&reasons Permit No. Date Issued 1 _ _ No. / ,� �y Fee ✓ THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: s - Yes . PU LIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS—— a y ; ZippYication for Migoal *pgtern Construction Verritit ,pphcation for a Permit to Construct( )Repair(X )Upgrade.( )Abandon( ) ❑Complete System ❑Individual Components ' at' Addres r Lot o t✓ wner's Name ddres Tel.No. Veep .o& Rd.. , C,,,ex� e ville, MA George Knight Assessor's a ���_16 G` 14 Mt . Pleasant Square, Randolph, DA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E-. Robinson Septic Service PC' Box 1089, Centerville, MA Type of Building: t . . F, Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persgns 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 Sand. r ;Nature of Repairs or Alterations(Answer when applicable) New Title-5 leach system. Heavy duty D-box and 2 Heavy duty leach chambers . °• Date lastinspected: ' Agreement: ! The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system i, g g g P Y in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cateof Compliance has been issued by t is and of Healt. Signed, �,_y.��-- Date[ "'4 j' Q g Application Approved by Date Application Disapproved for t followi g reasons Y, . Permit No. q�d 9 Date Issued THE COMMONWEALTH OF MASSACHUSETTS Knight BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by Wm. E . Robinson Seat is Service at 35 Peep Toad. Rd. , Centerville, MA has been constructed in accordance with the rovisions of Title 5 and the for Disposal System Construction Permit No. dated J InstallerWM. E. Rob ins on=Sr. Designer The issuance of this permi s n b ed as a guarantee that the s t i unct'o as desi d. Date Inspector THE COMMONWEALTH OF MASSACHUSETTS Knight PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS liopo.5af 6potem Construction permit Permission is hereby ranted to Construct( )Repair(X )Upgrade )Abandon( ) System located at 15 Peep Toad Rd.. , Cen erville, MA 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: 4 —-1 7c: Approved by N 1/6/99 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 DESIGNED PLANS) I, William E . Robinson,S,rhereby certify that the application for disposal works construction permit signed by me dated i o2,..<' ? d7l , concerning the property located at 35 Peep Toad Rd , Centervill P MA meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. JThe soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system V. 'There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor ashod when applicable] he S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed If t _ leaching facility will not be located less than Fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 6r B) G.W. Elevation +the 1VlAX. High G.W. Adjustment . _ DIFFERENCE BETWEEN A and B � / h SIGNED : y L DATE: L [Sketch proposed plan of system on back]. y:health folder:cent ri ar _� THE COMMONWEALTH OF MASSACHUSETTS BOARD OFHEA TTH O V` ... ...........of.....1�.�t.><'tnS. �...--------- ...............----- .40ratinn -fur Miivoiitt1 Workii Towitrnrtion Pprntit Application is herebymade for a Permit to Construct ( L/or Repair ( } an Individual Sewage Disposal Sys at: .-•................ ...Lp...-----------�----------•-----------•-..---------------_-------.....-----.-- ocation-Address or Lot No. W PP 1 ii Owner 6�� Add(es -..l-11_1;.�---.....-•--• CA.S !^5 t�.�.l..i.�..s........-..- Installer Address Type of Building //�� Size Lot---'_ �_ ....Sq. feet Dwelling—No. of Bedrooms------------1:�-------------------------Expansion Attic ((/} Garbage Grinder ( �jo aOther—Type of Building ............................ No. of persons.-_----------_-_---------- Showers ( ) — Cafeteria ( ) dOther fixtures ---------•--•---•-----------------•-•-----------•---------------------------------------------------------------------------------------------------- W Design Flow....................... ------------gallons per person per day. Total daily flow......................JAID...........gallons. 9 Septic Tank-_—Liquid capacity-j-09—gallons Length................ Width_---........... Diameter................ Depth---__....... Disposal �No. ...........---------- Width.....;f•/------- Total Length__...../.------ Total leaching area----yyd--- �q. ft.� Seepage Pit NAMPIP4....... Diameter.................... Depth below inlet..........._........ Total leaching area__----._._._-_-sq, ft. Z Other Distribution box (V,)* Dosing tanlSS ( ) Percolation Test Results Performed b �.(.Gl rya. !�� �_p i-�{e r, W Y-- e� �---- -••-- • ;�• - ��--.. Date---- -• ��- - ---------- Test Pit No. 1-_0_pl---minutes per inch Depth of Test Pit.................... Depth to ground water--.-.---.------.--.-_--- (4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ i. i�-------------------- -----------P.-------- -- ----- -- ------ x Description of Soil-----1 .- ... Q�.�"^--'•--•--k�'F ------ v�---�pl- _.-_T..�------- -�.t-- r U ---------------------------------------------------------- ----------------------------------------------------•--•-------•------------ ------------------------------------------------------------------------------------------- &AP n�--------------------------------------- U Nature of Repairs or Alterations—Answer when applicable._;---_----------------------- - ------------ -/Ot t k 1; -- --------- ----------------------------------------------------------------------------------------------------- ------------------------- ------------------------------------------------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the board of health. Signed----..E410^... !. Date ApplicationApproved BY------ -`A.............••••...... -----------•--•----•----------.... ............... .............// /4--'---7-)- (((/// Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------••••-•--••-......--- ------17 — Dat e Permit No.------ �-/ Z� ................ Issued._ .... Date -- -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEA�Ir $TH To kq Y.1111 .............. OF.... .Cxf..lC�S"�`:q. „ �x .gyp 1trtttinn -for Uhipooal Works C owitrurtion Permit App t,at ion is hereby made fora Permit to Construct (�r Repair ( } an Individual"`Sewage >Disposal Sys at: ( q f1 .o ,r . ate'--- .Q '.. _._.t.............................................................. P ocation•A-ddres or Lot No . ._ _ .--:.. _ �t ........................ `�_ .... a..�r�r�►- :c s -;-�-6--------- /� { ( Owner /� Address �A-t...-•• .. a ` Installer -� Dwelling gNo. of Bedrooms----------- _________________________Expansion Attic Address Gar age Grinder -----Sq. feet U Type of,Buildin Size Lot.. _.__ . pa-1 Other—Type of Building _----- No. of persons_____________________ Showers ( )bage Grinder ( +�0 — Cafeteria .( ) al Other fixtures ------------•-•------•-•------... W Design Flow_____________________1r.. .............gallons per person per day. Total daily flow.....................1._j_0__---..-.---gallons. WSeptic Tan1�� squid capacitvj0Od_gallons Length ........ Width................ Diameter_--- Depth--�-_ --.�j x Disposal —No. ...----• -- 4 Total.Length e Total leaching area_..�ft�k.. sq. ft...�s»�-Wicltli.-- -- _----- Seepage Pit N ------_ Diameter.................... Depth below inlet.................... Total leaching area-------.----------sq. ft. Zt Other Distribution box ( Dosing tan ( `-' Percolation Test Results Performed by._ _ f �_ 1 �. _A �_/�._t_ // dull___ _ �� . t { Date-Cs , 1 Test Pit No. 1-0-Al----minutes per inch Depth of Test Pit-................... Depth to ground water..._------_.._-._-.--.-. fT Test Pit No. 2________________minutes per inch Depth of Test Pit---_-_--_-_-•---.-- Depth to ground water........................ /y---------------------------------;' ---r " � �.i-tt- Description of Soil.----0.-._r3_---- ...... . .... . l ---- --------•--- W -------------- ;K. •---•----•--. ... .. ------....-- --------- +p °+_ - (, Nature of Rep•tW"„or.,Alterations—Answer when applicable-------------------- . •---- v Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bean issued by he board of health. Signed------ ,/.tiL' ..................----------------- ---- n Dat Application Approved BY . .11--- ' ?` "•�f_ Date Application Disapproved for the following reasons:............................................................ '... ...._. ...........................................................--------•-----------------_---------------.--------------------•----•----------------------------------------------.------------------------ Date Permit No...... `-/----------------------------------•-- Issued..... 2 . Date `1•HE COMMONWEALTH-OF MASSACHUSETTS s a. ;;BOARD OF HEALTH ........................................... . t Trrtifirate of 10.1"nrmpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) bY...........�......... ....r��;�I�.�� ---------- ln�k4 r.,....-,--- �-------------------•......----------- In,,,T has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__Z.0,,.-Y _______________________ dated-_ r1._�{f". .r.7--_-_____-__---.--- TF9E ISSUANCE OF THfS,"wC-ERTIRCATE SFIA,Ll ' BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUN TI l SATISF�TORY. DATE...... --•------ Inspector THE COMMONWEALTH OF MASSACHUSETTSfr BOARD OF �MEALTH •f� �.,t�,� J"` .................. Gy: .... ..OF... Fii?! G.............................................. No 7 - ....... Bispatial Norkii ClImnmtrurtion Permit Permission is hereby granted- ---------- 11 AA11I_el--------- :--------- --------------------------- ................................ to Construct]( ) or Repair ( ) an Individual Sewage Disposal System V}r'�r at N944;r-•------7----•.......1AVe i& r�'"' '- �= �� , y� ��..d�Jlt.�_..... �r I� ---•---- rStreet $ry. .�,. �« . KT as shown on the application for Disposal Works Constructign�Permit No.1 .. Dated //.'1 ?--7 i PP P k ,r --w �,+� --------•••- t< ----------------------- ---------------------- Board of Health DATE--•••••( . ......................... ----------------------------------- - FORM 1255 HOBBS & WARREN. INC..4PUBLISHERS�Xlx" qy a ! F��y.a; P :>• :, n -y'' M i t � 4>t+ ¢3S F'*W Y v�et,��� �" g 'r,,. Yti� aZ'.3 s 's�,Yi��wtfi� y }t � �..v / :..�(� .r a r 3" t �Jf>'= r t W' •L�,S r'¢r�, ! 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