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0112 POWDERHORN WAY - Health
112 POWDERHORN WAY CENTERVILLE A 170 022 d Mll • e�►s�ruts�,M� No.`QU l J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliCation for Misposal *pstrm Construction permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �'�6._ a `� O er' Name,Address,and Td No. Assessor's Map/Parcel %a O-trso^ �rn"ZZ.V CA Installer's Name Address andjel.No. Designer's Name,Address and Tel.No. ,I^V� 1k OV) YC—C—' Type of Building: Dwelling No.of Bedrooms Lot Size Ia sq.ft. Garbage Grinder(N) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) c� V gpd Design flow provided zq 6 gpd Plan Date- �4 l a,a i Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. a 0 11 :� ��► 9Z� S�c� Gia. Description of Soil TrP�f I—��7.Cm��-fit 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 Certificate of Compliance has been issued by this Board of Health. Signed Date L4f 9.- j f—? Application Approved by Date < � Application Disapproved by 0Date for the following reasons Permit No. 1. Date Issued -7 ( / No.'�_o C ( — ! t Fee l/V ..�..... THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair Ir ) Upgrade'( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ')d— 04 O};'ner's Name,Address,and Tel.No. Assessor's Map/Parcel 'a 4'a gad,*r f�. t f\ ��y A��sol\ Installer's Name,Address,andT el.No. Designer's Name,Address,and Tel.No. 5�.d w r, �'<<,.�•� 1�-3 O l� Y�CMo t�J S Cc�-e� �tc�.S S"r�� 36;t t G r ti'f bb b f3 l to :Sau�.. i� C^S a.f.6U Type of Building: Sr a Dwelling No.of Bedrooms Lot Size S 13a sq.ft. Garbage Grinder(N)U Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 0 gpd Design flow provided 3u K gpd Plan Date 1 ' ((`� Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. %4 a U n$�rxx Q C) Description of Soil C�cniti.� 1 ] �{ W �c 2 S Q / X oT Cc2 �P.�io • fhor` rr...,r r�� ��I.J�C� . lr , Nature of Repairs or•Alterations(Answer hen applicable) ���C� !�c�. L o c ck,, C.rC.G ,. Date last inspected: " F 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 Certificate of Compliance has been issued by this Board of Health. 4 } Signed Date 1.� o`Z 71 1"7 Application Approved by _ ��- Date l Application Disapproved by Date for the following reasons Permit No.an k-7 Date Issued `t a-7 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(t/) Upgraded( ) Abandoned( )by - at- -j t0— has been constructed in accordance with the provisions of Title 5 and the fdr Disposal System Construction Permit No. dated Installer SCh M �r{���o_ Designer #bedrooms _ Approved design flow Cl,� gpd The issuance of this permit-shhadil no 4e construed as a guarantee that the system wi11-f 1Wc-tio,-as,design Date / Inspector \ ! i No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS MispoBal *pstem Construction Vermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at k_)� n r r, and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 �/ / D- 1 -7 Approved by Pq a V A.; I F ' Town of Barnstable Regulatory Services 'Richard V. Scali,Interim Director Public Health Division Thomas McKean,Director --- 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Sewage Permit# Q n�—7--115 Assessor's Map\Parcei l 70—ad Designer: SMP f{Gf a ik. ikA kS.Pam'" Installer: Address: C 6 Address: cis OL.?,%., C�AeJ400T'4 i "A g yk oQ t S . k A. c24ao I On -7 was issued a permit to install a (date) (installer) septic system at t�a �>oo_&<J-�On, L,)c y Cv-��'e- based on a design drawn by (address) "&=i! t�6�-J . - " ' dated Li 1 ,2q }`1 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed itr 1* cc with the terms of the M approval letters (if applicable) (Installer's Signature) > (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:ISepticlDesigner Certification Form Rev 8-14-13.doc Town of Barnstable P# .5�3°e)Departinent of Regulatory Services -7b -7 i F Public Health Division Date MABS, tdjp. 200 Main Street,Hyannis MA 02601 . t�rll Mid Date Scheduled 7Ti'ma--� Fee Pd._ Sail Suitability Assessment for Sewage Disposal Pcrformed•By: �ex� Witnessed By: i LOCATION&.GENERAL INFO ORMATION Location Address Owner's Name Address I Assessor's Map/Parcel: % 710 --G `'J-' Engineer's Name v ` c\c, I • NEW CONSTRUCTION REPAIR +� Telephone# Land Use--- + •"'r►.4-�. es Slo 96 - /c' p ( ) Surface Stones �C.� Distances ftom: 0 en Water Bod dac p y e ''�ft Possible Wet Area ft Drinking Water Wcll Nl� ft Dralhage Way 1A. ft Property Line ltl ft Other I ft . i i SKETCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands-in proximity to holes) w 4 . N Paront material(gcologle) �T�T""�s+r Depth to Bedroak Depth to Groundwater. Standing Water In Halo: Weeping tYolrl Pit Fnoe Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL•HIGH WATER TA13LE ii Method Used: Aa%� Do th Observed standing In obs:hole: In. Depth to soil mottles. In.' Do�th to weeping from side of obs.hole: In, Groundwater Adjustment I fit. Indox Well-# Roading Data: Index Well lmvol Adj,•factdr, ,_. Adj.Grawidwateai e4M1,.,_ PERCOLATION TEST note _- Time Observation ALL Hole# ' Tinto at 9" Depth of Peru S Z Time at 61, Start Pro-soak Time @ b c.0 Tltno(9114" ,. End Pro-soak Rate Mln./Inoh 2 Sho Sultabillty Assessment: Sltd Passcd i✓ Sup Failed: Additional Testing Needled(YIN) Original:.Public Health Division Observation Hole Data To Be Completed on Lck---- — ' ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISBPTICIPERCFORM.DOC I DEEP-OBSERVATION HOLE LOG Hole#_I Depth from Soil Horizon Soil Texture Shcl Color Boll• Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stonat,Boulders. isistency.%'l3rsvel) ZY " a L S 32" L S IV`1i� Slty � 32 ,, -C DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Sol]Color. Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. 144 DEEP OBSERVATION HOLE LOG Holly# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Solt Color Boll Other Surface(In.) (USDA) (Munsell) Wiling (Structure,Stones;Boulders, Flood Ingurance_Rate Man: Above 500 year f lood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No.,,-f_. Yes peAth of Naturally Occurring Pervloua Ma erlal Does at least four feet of naturally occurring pervious material exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what is the depth of naturally occunibg pervious material? Certification I certify that on ii /`� S, (data)I have passed the soil evaluator examination.approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,cx se and experience described in 410 CMR 15.017. Signature Date u zo�7 Q:%SBPTlCWRRCPORM.DOC YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates COST $30.00 for 4 years. A Business Certificate ONLY v (WHICH YOU MUST DO BY M.G.L. - it'does not give you permission to operate). You must first-obtainthe S necessary signatures es �n the Town at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, I" Fl., 367 Main St., Hyannis, MA y g on this form the Business Certificate that is required by law. Y 02601(forvn Hall) and get E" = " : j E' Fill in please: DATE: ZJ w nn q.; i ..:'.? „ � ;r, ; *:';;; APPLICANT'S YOUR NAME: ��e�n �/ . 4 ; � -+r <i•;"+.:Fr` BUSINESS R �;,�r�+. . _ •:,;, -- HOME ADDRESS H TELEPHONE # �� c t11 Z NAME OF NEW BUSINESS r' Home Tele hone Number: O a IS THIS A HOME OCCUPATION? �N �7C TYPE OF BUSINESS YES �.� �"rnrj�.fcA NO Have you been given approval fr%� the, bujjlding division? YES NO ADDRESS OF BUSINESS ✓/ YOiUC/PALI�no Wa. � It MAP/PARCEL NUMBER When starting a new business there are several things yeu must do in order to be in compliance with the rules Barnstable. This form is intended to, assist you in obtaining the .information you may need. You MUSTGO TO 200u1M ins t. the Town of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business ner s town. in this I. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. , Authorized Signature** COMMENTS: ' 2. BOARD OF HEALTH This individual has been i rme of the permit requirements that pertain to this type of business. Authorized Signature** MUST COMPLY WITH ALL COMMENTS: Y HAZARDOUS MATERIALS REGULATIONS G 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: TOWN OF BARNSTABLE Date: y/ZS/ It TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: P2$-N 17170--1 BUSINESS LOCATION: _Ilo? d�2ly� 1,(1� ��rv'IL MA �Z�37� INVENTORY MAILING ADDRESS: _ ,r,�t TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: 774-4 8`7 `&,2 -3 MSDS ON SITE? TYPE OF BUSINESS: keg' 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 MUSED 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) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash C WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Signa are Staff's Initials �.-.� YOU WISH TO OPEN A BUSINESS? � For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: °� `7 200 7 Fill in please: y APPLICANT'S YOUR NAME: �2S,oN �'� �4 BUSINESS YOUR HOME ADDRESS:-!i'4 508 7°i 0ZJ1'3 r"4_r UW0_ m rt o zr'3 Z TELEPHONE # Home Telephone NumberSo£3 . . .:..-:...._ _. 7'h*i'...,�. ..$.-E 2- rr S-.E:'�;:t-zS�»OFBISINEBUNAM �r. ��YP E" , H,THIS,A OV d�eTR y.,�...�,,.I,a-iryyp F tt.,"a`a w_pY✓:..y:'" z�.. w:c OCCUPA.. .•, � ,.. ._ , ., ._;, �,, ,�.y ;� _..,,, , : ,;: -.: x,n ,.P. ..- aye o:u,be:en 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 o 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 COMM ONER'S OFFICE This inc lu 4hAu e n info e o any permit requirements that pertain to this type of business. orized Signature** MENT T r 2. BOARD OF HEALTH This individual has bee forme f the mit requirements that pertain to this type of business. �horized gnaure* 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 — _ Hazardous Materials Inventory Sheet Checklist Iit 1156 Date —��Physical Street Address-Check database to ensure it exists —� Working Phone Number Actual Amounts-(le.gas being used to fuel machines,thinner to clean brushes all count as hazardous materials) Storage Information-location of storage,how long is storage for? If none,note.that. ✓ Disposal Information-where and who?If none,note that. Applicant Signature-understand what is listed and noted i —�^Staff initial-any questions,know who to ask Vehicle Washing/Rinsing? -provide a vehicle washing policy and / explain it-note that it was given Attach the Business Certificate with your sign off and comments "The inventory form should explain what the business consists of and the procedures I, they are doing. Notes need to be left to explain what you discussPri with rho.,, Date: / y /0 r.� TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: >A �� L4 9lNn/q (.— BUSINESS LOCATION: 112 ?9wdee,eo2n ltra/k A-742 Q Wti Z INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: SV8 - "Od_3Y3 CONTACT PERSON:- &2eR_&00,j G- �,A ge-`�,o l4 EMERGENCY CONTACT TELEPHONE NUMBER: 508 ?���3� 3 MSDS ON SITE? TYPE OF BUSINESS: INFO ATI /RECOMMENDATIONS: ( � �® �Y !� hjAI" 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 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 Observed/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, c 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 hazardous (please list): Laundry soil & stain removers a r n (including bleach) Spot removers & cleaning fluids (dry cleaners) �'�1►n v`' —T Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS e a YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost$30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1st FL., 367 Main Street, Hyannis, MA 02601 (Town Hall). DATE: /Z O Fill in please: _ APPLICANT'S YOUR NAME: BUSINESS YOUR HOME ADDRESS: � t��n�ervi11e. In 02-6 TELEPHONE # Home Telephone Number: (ST38 7go.-13 Y3 NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A'HOME OCCUPATION? YES NO Have you been grverl approval from the bulcl�ng clrv�sion� YES NO ADDRESS OF BUSINESS llo� /w�2f"d�oX .. ` +'ti►//� rn •z-MAP/PARCEL NUM$ER 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 This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature" COMMENTS: 2. BOARD OF HEALTH This individual has V informed of the ermit re irements that pertain to this type of business. uthc 'zed Signature" COMMENTS: eo-Z 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual h een inf�of t ie li n in requirements that pertain to this type of business. Authorized Signature" COMMENTS: �i Date: Z `� ('o v, TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: 0/�-Z7& 14 7.91rA BUSINESS LOCATION: &Z �wdee &a ce4tLdh 026�2 MAILINGADDRESS: Mail To: TELEPHONE NUMBER: CJ� Board of Health CONTACTPERSON: &-keRSc,� a�. Art y stable P.O. Box 53 Town of Barn EMERGENCY CONTACT TELEPHONE NUMBER: (��4)4 ?'�YZ Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES t/ NO 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 otherthan your mailing address: ADDRESS: 1121 ?,G,00,Q e_"Q__A Ce-rA e�;l le nl OZG-3 TELEPHONE: (S b `7 Oa B 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 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 ZS Paints, varnishes, stains, dyes —" PCB's Lacquer thinners _ Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) �S S Paint & varnish removers, deglossers — Any other products with "poison" labels .A Paint brush cleaners (including chloroform, formaldehyde, Floor& furniture strippers hydrochloric acid, other acids) Metal polishes -- Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: ��� � �� r.i� BUSINESS LOCATION: //cZi &wde e- een CPS ,r�'�/ 0243 Z MAILINGADDRESS: Mail To: Board of Health TELEPHONE NUMBER: �J'�) `T�Oo2��P3 Town of Barnstable CONTAC rP„ERSON: N1 R � P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: (`7r14�4 ? Hyannis, MA 02601 TYPEOFBUSINESS: 3 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES L/ NO 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: ,tZ ��:��� �,�Re c CE,v1e.d? TELEPHONE: Cab `? Oct `P 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 gasoline asoline or coolants systems)Y ) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants -- Engine and radiator flushes — Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel y" 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 ZS S Paints, varnishes, stains, dyes PCB's r --- T — _Lacquer thinners. IT-- _ _ : ._ _ y. --Other--chlorinated-hydrocarbons;---- ,-------- NEW USED (inc. carbon tetrachloride) S Paint &varnish removers, deglossers � •f ____ Any other products with "poison" labels .moo Paint brush cleaners (including chloroform, formaldehyde, — Floor & furniture strippers hydrochloric acid, other acids) — Metal polishes -- -- Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bugland tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS J TOWN OF BARNSTABLE ?LOCATION k Q VW6�4� L3LN SEWAGE# 0 \lC1 VILLAGE (.4 AS� \,\-P_ ASSESSOR'S MAP&PARCEL \_)o- Q a. INSTALLER'S NAME&PHONE NO. �C�1�, C� r"r��, :5bX Z`jSA 060 SEPTIC TANK CAPACITY 'P_M sA .Z p b 0 Gr&L �A a,& Q a tox LEACHING FACILITY:(type) ],() S_6(3 GaL (size) l xNC S,�X .1 1pai Ctn�+ 6�S NO.OF BEDROOMS OWNER ��.��ef ( y 1pr 9\c, PERMIT DATE: I 1 l 0 COMPLIANCE DATE: 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) 1Vo 1 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY S C C (� w3; ,�� ( ��� S- w` J a I 1 { COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. DEPARTMENT OF ENVIRONMENTAL PROTECTION y y • TITLE 5 OFFICIAL INSPECTION:FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address:. 2Z lDs� APR 1 6 2002 A Owner's Name. STABLE Owner's Address: c T�WHEALTH N OF BADEPT. Date of Inspection: f7^®� Name of Inspec yr: please print) �� �- v ' VCJI b10 f 0 PARCMCompany Nam n Mailing Addres0- ny -/G - � Vd- - Telephone Number:k �-`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 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 Needs.Further Evaluation by the Local Approving Authority. Fa s Inspector's Signature: Date: A z 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. 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 how the system will.perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 r 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) `Property Address: (' Owner: Date of Inspection: �'.�QGQ-, Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: w B SystiemnConit ovally 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. 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 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. ND explain: 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 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: 2 i y Page 3 of l'l OFFICIAL INSPECTION FORM., NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owne Date of Inspection: QG C. Further Evaluation is Required by the Board of Health: Conditions.exist which require further evaluation by the Board of Health in order to determineif 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 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 I OQfeet 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 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. 3. Other: 3 Y Page 4 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: . / d Owner. Date of Inspection: ,� �, 000a A System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to'each of the following for all inspections: Yes No/ b Backup of.sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or.ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cessP ool S Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or P cesspool ool _ _,f Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow V 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 onion of cesspool or ri is within 10 P p p ivy 0 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone l of a public well. . Any portion of a cesspool or privy is within 50.feet of a private water supply well. Any portion ofa 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 it 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 co of the analysis must be PY Y attached to this form.) (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 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 criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;PART B CHECKLIST Property Address:_-�/K) �Q,27 Ownerklzz l� Date of Inspection; ,Q400 Check if the following have been done You must indicate"yes"or"no"as to each of the followins; Ye lei E/ Pumping.information was provided by the owner, occupant,or.Beard of Health ✓`Were.any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ZHave large..volumes.of water been introduced to the system recently or as.part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as NIA) Was the facility.or dwelling.inspected for signs of sewage back up? Was the site inspected for signs of break out? tom_ 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: Yes no 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .,PART C SYSTEM INFORMATION Proper ty P Y Address: � Owne Date of Inspection: cs� FLOW CONDITIONS RESIDENTIAL Number of Bedrooms.(design): : Number of bedrooms(actual): DESIGN flow base don390C 1520 0 3 for exam le: 11.0 d x#of bedroom (� P bP x s)• Number of current residents:I� - Does residence have.a garbage grinder(yes-or no�—A& .Is laundry,on a separate sewage system (yes or'no): ,[if yes separate inspection required] Laundry system inspected es or no . Seasonal use:(yes or no). . Water meter readings, if a ilable(last 2 years usage Sump pump(yes or no)L. &0-- Last date of occupancy: zon • Q&&to COMMERCIXUINDUSTRIAL. i,.lxe-� Type of establishment:.. Design flow.(based on 310 CMR.15.203): gpd Basis of design flow(§eats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste.holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records -Source of information: v Was system.pumped as pa of the inspection(yes or no): If yes,.volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: . TYPE OF SYSTEM _1Z,<eptic 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 frorh system owner) —Tight tank _Attach a copy:of the DEP.approval _Other'(describe): Approximate age of 11 components,date inst lied(if known and source of information: Were sewage odors.-detected when arriving.at the site(yes or no 6 Page 7 of 11 OFFICIAL INSPECTION FORM—,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: / _ � . Owne Date of Inspection:. �O(�©& BUILDING SEWER(locate on site plan): jJ`- Depth below grade: Materials of.construction: • cast iron _40 PVC_other(explain):- Distance from private water supply well.or suction line: 'J - Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:Zoocate on site plan) ri Depth below grade: i Material of construction:concrete_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: Sludgedepth: Distance from top of sludge to bottom of outlet tee or baffle: 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 _ How were dimensions determined- i � Comments(on pumping recommentions,i let and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert,evi ce of leakage,etc.): GREASE TRA��Locate on:site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage;etc.): 7 Page 8 of 11 OFFICIAL;INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: jCle Own Date of Inspection: a9, aC a TIGHT or HOLDING TANK:Lt,,<tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass Polyethylene _ other(expWh Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last'pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: y (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: �tont;oComments(note if box is level and distribts equal, any evidence of solids carryover;any evidence of kage into or out of box, e c.): ot% PUMP CHAMBFR./Jd&-0ocate on site plan) Pumps in working order(yes or no):_ Alarms in working order(yes or no):. Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 I Page 9 of 1 I OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /k:) Owner. a - 11 Date of Inspection: p� SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type l aching.pits,number:_ leaching chambers,number: aching 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, et CESSPOOLS- i (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.): PRIV�(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,,etc.): 9 Page 10'of l l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :PART C SYSTEM INFORMATION(continued) Property Address: I lly— Owner: "c ( D Q Date of Inspection:_ /lito.B7 c�;q, cooa 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. a j- \ 1 �Q [�l 0., 7 [ s —I (33 i 10 i Page I I of 11 OFFICIAL- INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: '-C/l— Owner. X _ Date of Inspection: / ooa SITE EXAM. Slope Surface water Check cellar. Shallow wells Estimated depth to ground water feet 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-(attach documentation) 17 Accessed USGS database=explain: You must describe how you established the high ground water elevation: 11 i Permit Number: Date: Completed by:. t r/ HIGH GROUND-WATER LEVEL COMPUTATION �/Z ���� �l��� Site Location: � � �'����,o'llE�` Lot No. Owner:_ Address:. A Contractor:_ ffatz� �.,l�i10 Address: / ✓�� '/''� •�'% �l� Notes: STEP 1 , Measure depth to water table to nearest.1/10 ft................................. ................:............ .Da e 3/pk_ 1 month/day&ear STEP 2 Using.Water-Level Range Zone and Index Well.Map locate site anddetermine: -• O Appropriate index well................................................... . �klZ`J OWater-level range zone.............. STEP•,:3:.. Using month ly.repo.rt;:"Current ,. Water Resources Conditions" determine current depth to 1 water. Level for.index well ........................... month/year STEP. fit•. Using.Table of.Water-level Adjustments for index well (STEP 2A),.cur.rent depth to water level for index well (STEP 3), and water-level zone (STEP213) determine water-level adjustment ............................. J STEP. 5 Estimate depth to high water by subtracting the water- level adjustment..(STEP 4) from measu.red;.depth to water level at site, (STEP 1) .......................................... ......................................,............................... Figure 11--Rearoiducible computation form: 15 �; _ V.: g jll Fqmgmx Dining ° FYrd Floor a� nn PIHII Tt L stirIr Ell — I 7 , � I I I I I I i I 71T1 �i�I91� ■- I F!�wtina FOl1IIdB�OII Man. • Cr4sllMCN7 NOTld� � ® 90 • � Q Kill , Ream Boom !! Bedroom a Second Plenr Plea Ci f i"Rr®wwrlr+lue� � B .emu �a g mm �0 1� Front Elevation f� n� rrs � Rear Elevation � in Q 7�bro "Iwo •r.s Riyj%t Side Movation pill Y Mill �a t a V_ K Left Side Elevation .0 YY �' LillQ rcr�sr� g s w = yy Y ff Y Em m flan Ii�`■1� �' �a� r�r.a ��=�iwl■ t�rR w� Kira wIM Bdh 1h1f�te H�eaa as Rdh w .00 -Y ----------- R f R >y■1■1 w u t mm Z -MAMS we■..r■ ��li wrw�w■ wR fad ii—�aaa— A�� . N1��r lµl�j ■ ■ I I rw" Y H ical C ee 9eotio /-AN Crow logtkn �r 9 �• � Q r AwYLT i�W 11RCML KILL ANNLT WPM w�.tiny wnw �yGIL,��{� KV- Y. � ORIDGE VENT DETAIL O TYPICAL. SILL. DETAIL y Nf.M �AYr.M mill MA{1. ALU y IN O&W 0!r rating awr own s n W y M�Aw •nL ITT 1AAlNI r ------A=PIT.•wa&— oom nrrw� +. ® TYPICAL STUD WALL �AFIl.M w ODWK • SILL DETAIL (NO RAILING) 9 ,12 Lill4 d r Fee 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migooar *pgtem Conttruction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 112 Powd.erhorn Way, Centerville John Wasierski Assessor's Map/Parcel / 70 — U 2� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville 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 Sand. k. Nature of Repairs or Alterations(Answer when applicable) new Title-5 leach system all around 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 th' o of Health Signed Date`- --�8 -'e� Application Approved by AgL— , -ift Date — 00 Application Disapproved for the following reasons Permit No. `6 Date Issued N_o:'�(bb f7���.l " Fee $ 0 z THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zlppricatio � for Migpogar *pgtem Congtruction Ver it � j Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address"an d Tel.No. �0 112 Powderhorn Way, Centerville John Wasierski Assessor's Map/Parcel 0 — 0 2 r Installer's Name,Address,and Tel.No. Designer's Name,Address andu�'el.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville s Type of Building: Dwelling Nct of Bedrooms 3 Lot Size sq.ft. GarbaggrGrinder(I ) 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 `Revisi_op De Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. -1 r Nature of Repairs or Alterations(Answer when applicable) new Title-5 leach system consisting of R — _ all around , .s Date last inspected: as Agreement: s The undersigned agrees to ensure the construction and maintenance of the afofe described on-site sewage disposal system n 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 hi p of Health. Signed ! ' r Date " �--� Application Approved by Afi��, �D Ud"4 d Date — 0 Application Disapproved for"the following reasons ;1 Permit No.J,&,o, a � � Date Issued THE COMMONWEALTH OF MASSACHUSETTS Wasierski BARNSTABLE, MASSACHUSETTS " Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed.(.,,, )Repaired (Xf`)Upgraded( ) Abandoned( )by Wm. E.Robinson Septic S e ry e e at 112 Powderhorn Wa.V, CPntArvi 1 1 A has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Wm- E. Robinson S r. Designer The issuance of this permit shall not be construed as a guarantee that the system ill function as designed. Date �P - ,�% Inspector --------------------------------------- No. Dar-' : Fee $50 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Wasierski ligpogar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) Systemlocatedat 112 Powderhorn Way. Centerville 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:_� —t�d Approved by _,�3. 116/99 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(WrrHOUT DESIGNED PLANS) Y William E. Rob ins on,5xltereby certify that the application for disposal works construction permit signed by me dated � ' ��� , concerning the property located at 112 Powd erh orn Inraw., C ent eru-L I I o meets all of the following criteria: • The failed Vqm is connected to a residential dwelling only. There are no commercial or busincss uses associate with the dwelling. u The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. /Th o wetlands within 100 feet of the proposed septic system o private wells within !Sq feet of the proposed septic�ysten► increase in flow and/or change in use proposed o variances requested or needed. of the proposed leaching facility will not be located less than five feet above the adjusted groundwater table elevation: f Adjust the groundwater table using the Frimptor method when applicable) • If the S.A.S.Nvill be located with 250 feet of any vegetated wetlands,the bottom of the proposed 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 G1S information) Z B) G.W. Elevation +the NLkX. High G.W. Adjustment . ---- DIFFERENCE.BETWEEN�A and B SIGNED : b L. ( DATE: (Sketch proposed plan of system on back). y:health folder:cen s- . .. �. l2� ^ -. ''�../� // �� G.�J ,C i ` / ��` � . . .� ✓'� C � � ^, o�� I TOWN OF BARNSTABLE t; ; C LOCATION SEWAGE #267�a 8� VILLAGE_ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. T64/A' 6 SEPTIC TANK CAPACITY J6_6 6 LEACHING FACILITY: (type) --lCld ? L— (size) /c1_2! _ NO. OF BEDROOMS .3 BUILDER OR OWNERS PERMITDATE: COMPLIANCE DATE:'!,/V-66 Separation Distance Between the: Maximum Adjusted Groundwater Table to the ot tom of Leaching Facility Feet Private Water Supply Well and Leachi g Facility (If any wells exist on site or within 200 feet of lea tng facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet j i I 0 TOWN OF BARNSTABLE JLOCATION 12 Pawkier bnrn SEWAGE # VILLAGE an�cr,"lle ASSESSOR'S MAP & LOT J:Z J=0 2 2 INSTALLER'S NAME&PHONE NO. K ob%n Sv, SEPTIC TANK CAPACITY DO LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: �—3 _OG COMPLIANCE DATE: 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 Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Fumished by J I �3 o T �N n r' -r TOWN OF BARNSTABLE ele- is LOCATION � J 3 ��' d' r am. SEWAGE # 00 VILLAGE ( e ty,, ASSESSOR'S MA tSz.LOT 76-U"�-a- INSTALLER'S NAME & PHONE NO. 110611DIM,1144e aff—i� C/ } SEPTIC TANK CAPACITY , LEACHING FACILITY:(typc) el 7 (size) NO. OF BEDROOMS PRIVATE WELL O UBLIC W BUILDER OR OWNER �`� //Zf / DATE PERMIT ISSUED: - C DATE COMPLIANCE ISSUED: -7 - f " VARIANCE GRANTED: Yes No �/ �� . -, •+ r C� ��� C� _ � � ' . . � � � - � � � i COMMONWEALTH OF Mr',SSACHL;SETTS _ EXECUTIVE OFFICE OF EINVIRON MENTAL AFFAIR` DEPARTMENT OF ENVIRONMENTAL PROTECTION -r4'c r ONE RNINTER STREE7. BOSTON DLL.0210c 1617j 292-550k, TRL DY COXIE Secre:a--. ARGEO PAUL CELLLICCI DA'7D B STP. 'HS Governor Corrunussione- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 112 Powd.erhorn Way Name of Owner John Was ierski Centerville Address of Owner: Date of Inspection: G—V Name of inspector:(Please Point)Wm. E . Robinson Sr. I am a DEP approved system inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) rn CopanyName: Wm. E . Robinson Septic Service Mailing Address: P4 Box 0 9. Centerville MA Telephone Number: 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-site/sewa a disposal systems. The system: s Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �✓tJ i 1, r �� Date: _EA— 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 lfte system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS 0,: .� ?0 00 �(ty�tiST rev1sed 9/2/98 PaRvIof11 n 1�• •^red on Rea•c;rd Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) "rop"Address: 112 Powd.erhorn Way, Centerville owner: John Wasierski Date of Inspection: INSPECTION SUMMARY: check-*A A C, o/ D: A. 77S PASSES: I have not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. STEM CONDITIONALLY PASSES: One 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 y s, 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 pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revise: 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 112 Powd.erhorn Way, Centerville Owner: John Wasierski Date of Inspection: C. THER 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. 11 YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303 11)(b)THAT THE SYSTEM 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) YSTEM 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) OTHER revise--� Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PtopertyAddress:112 Powd.erhorn Way, Centerville owner: John Wasierski Date of Inspection: 41— Zl- O'U D. SYSTEM FAILS: You MUN indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will bi necessary to correct the failure. Yes o 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 112 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets). 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. LARG SYSTEM FAILS: You must i dicate either "Yes" or "No" to each of the following: T e following criteria apply to large systems in addition to the criteria above: T e system serves a facifity with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public ealth 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 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. revised 9j2/98 Pagc4ofII I ' 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 11.2 Powd.erhorn Way, Centerville Owner: John Wasierski Date of Inspection: 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. I , _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrialwaste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ 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: 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) / (1.5.302(3)(b)) v - _ The facility owner (and occupants,if differeru from owner) were provided with information on the propermaintanaaco-0f Subsurface Disposal Systems. rev, sea 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART C SYSTEM INFORMATION 'rop"Address: 112 Powd.erdorn Way, Centerville Owner: John Wasierski Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: L Qg.p.d./bedroom. ? Number of bedrooms Idesignl:� Number of bedrooms(actual):- Total DESIGN flow W Number of current residents:-& Garbage grinder(yes or no):.&® _ Laundry(separate system) (yes or no)2/4; If yes, separate inspection required Laundry system inspected Eyes or no) Seasonal use (yes or no): z O 1999 95► 000 gal. Water meter readings,if available (last two year's usage(gpd): Sump Pump(yes or no):A—.16 1998 79, 000 gal. Last date of occupancy:_4--LV CO ERCIAL/INDUSTRIAL: Type V establishment: Desig flow: gpd 1 Based on 15.203) Basis design flow Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-sen tart'waste discharged to the Title 5 system: (yes or no)_ Water ter readings,if available: Last dat of occupancy: OTHE (Describe) Last to of occupancy: GENERAL INFORMATION PUMPING RECORDS6ndoye of information: System pumped as part of inspection: (yes or no) If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) 1/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 lif known) and source of information: g5 A 6 6�� � � o3 Sewage odors detected when arriving at the site: (yes or no)w v 9 revised 9/2/91 Page 6(if 11 I - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address:112 Powd.erhorn Way, Centerville Owner: John Wasierski Date of Inspection: BUILD G SEWER: f (locate site plan) Depth bel w grade:_ Material construction:_cast iron_40 PVC_other(explain) Distanc from private water supply well or suction line Diameten Comme : (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) 1 Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) a J�► Dimensions: �., & Sludge depth: I` Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 1 f Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of�tlet tee or baffler How dimensions were determined: ;omments: (recommendation for pumping, condition of inlet and outlet tof or b&ffLgs,,depth of liquid level in f elation to outll t} vert, ructural int ity, evidence of leakage, etc.) J'' GREAS TRAP: (locate o site plan) Depth bet grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimension Scum thick ass: Distance fr m top of scum to top of outlet tee or baffle: Distance f m bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Comme s: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evide a of leakage, on revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) +rop"Address112 Powd.erhorn Way, Centerville Owner: John Wasierski Date of Inspection: TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth be ow grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene other(explain) Dimensi0 s: Capacity gallons Desig ow: gallons/day Alarm resent- Alarm' I vel: Alarm in working order: Yes_ No_ Date of revious pumping: Commen s: (conditi of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:�Z Comments: (note if level and distribution is equal, eviden lof yo' s carryover, evidence of leakage into or out of box, etc.) - PUMP CH MBER:_ (locate on ite plan) Pumps in w rking order: (Yes or No) Alarms in w rking order(Yes or No) Comments: (note condi on of pump chamber, condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address:112 Powd.erhorn Way, Centerville O-rw: John Was ierski 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:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, dams soil, condlion of vegetation, etc.) 1'O CESSPOOL _ (locate on sit plan) Number and c nfiguration: Depth-top of li uid to inlet invert: 7epth of solid layer: )epth of scu layer: Dimensions of cesspool. Materials of c nstruction: Indication of roundwater: infl w (cesspool must be pumped as part of inspections Comment . (note co on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) Materials of construction: Dimensions: Depth of solids: Comme ts: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revise: 9/2'/7` Pagr9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) bopertyAddress: 112 Powd.erhorn Way, Centerville owner: John Wasierski Jate of Inspection: 41/./ mG 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) -e a S3 revised 5;2/9? Page 10ofII ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) roperty Address: 112 Powd erhorn Warr, Centerville Owe: John Wasierski 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 1 Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record V/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) revised 912198 Page 11 of 11 TOWN OF BARNSTABLE , G, •Dc�CL a T'SEWAGE # " a' d LOCATION f` r .� n- VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY `� Z L y�(size)./9 LEACHING FACILITY: (type) ��� 5 �^ NO.OF BEDROOMS 3 r _ BUILDER OR OWNER Aga, t '�&icy PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the'Bottom of Leaching Facility Feet Private Water Supply Well and Leachi g FFacility (If any wells exist on site or within 200 feet of lea tng facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ./ L �n6 � ,` ' d6' •: ©� �s z� �� y 9� 1 1 e � _'i /' ��� � Q ASSESSORS MAP NO: 70 Fizz...... Y.......... THE COMMONWEALTH OF MASSACHUSETTS 1 �){BOARD F EA T .........OF... ......... . ................... Applira#ilau for Bhipvii al Workii Tamitrurtiuu Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: ®0W41e41-1?0v-11 � e S )A14- �¢/V%��lr iL�iz ........•--•....----------•.........�.................... �•. � - Loc Add f°c�� �� or Lot No. . fi - ��. .. �/ 7----------------- ------- .----....---- IIOwner.• � --------------••-.•.•-.••--•-.--Address FW1 ................. v_i...... .�J......_.. ................................. _.......... •-•---------........................._. Installer Address Type of Building Size Lot... ....St U Dwelling—No. of Bedrooms.......... .Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons__-_---.-_-__-___________- Showers ( ) — Cafeteria ( ) aOther fixtures ...._----------------------------------------------------------------------------------- W Design Flow............................. _-•__gallons per person per day. Total daily flow____3� ._.._._......................_gallons. WSeptic Tank—Liquid capacity/5�--gallons Length,/ Width.__'G__`ZA__ Diameter__-=...... Depth mod'._. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.___-.--__-I------- Diameter....flQ�__.____ Depth below inlet._ ?_ Total leaching area... �-•-sq. ft. Z Other Distribution box ) Dosing tank ( ) Percolation Test Results Performed by.__,44�.�- t'�� - - , ____________________ Date._.� ............ ,aa Test Pit No. 1.......,-....minutes per inch Depth of Test Pit----ZZ";_____ Depth to ground water.......... ............ (i, Test Pit No. 2........Z....minutes per inch Depth of Test Pit____IZ'__.__. Depth to ground water--- t ._.-----__. 0 R+ ----------•-•---------- ............. .............. ..................................... _............................................... Description of Soil------ i�s3....... _....... _ r`"f v �j-1 % ,:.�a��� ............................................... x V ------------•-•--------------------------- -----------------•---•-•---..._...._.._._..._.....---------------------------------------------------- •------- •-------- •----------------- --------------------- W -----•-----------•-----------------•-------•----•---•-•-------•-•-•-•------•---••--•------•-----•---- ••--------••--------------------••-----•-••-••••--•-•-•-•--•------•------••-••-••--•......•------- UNature of Repairs or Alterations—Answer when applicable._____________________________•.____-_.-___._-------•-._-.---__-___-_---.---.----------------__. Agreement: The undersigned agrees to install the aforedescrib ndividual Sewage Disposal System in accordance with the provisions of iIT .;.;. 5 of the State Sanitary Cod — e undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sue y the ba th. Signed •-----. -- •--••-... •• Application Approved B Date Application Disapproved for the following rea s:......................••••-•--•------------------•-•-•-••--------•-••-••---•--•-----••--•-•-•----•-----•-•...... --•-----------•-----•-•--•---------•---------------------------------------------------------------------•------------•-•-••-•----•--------••----•-------------•--•--•-•-------•--•----•-•---•••-------- Date Permit No...-tC)--.a---�- --•---•------- -------------•----•--- Issued--_-------•----------------- ------ Date FE$....._. .. ........ THE COMMONWEALTH OF MASSACHUSETTS /. BOAR® I D ....... F H.EA T �.....OF . .. . . � .................... Appliration for DWIua1 Marko Tomitrtirtion 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .......... / (� jjLoca' Add or Lot No .... �[.. .. _._ /yi.. a/- ....._...-•.......... .........•----....--•-•-•-----............ ............................................ ^ Owner Address d. Installer Address Type of Building Size Lot___ : s_-ei_. ..sq;=f et U Dwelling—No. of Bedrooms........... ____________________ _Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures - ------------------------------- - W Design Flow............................._�___�.-...gallons per person per day. Total daily flow____��___.�..`1____.__...__.___ ___.-___.___gallons. WSeptic Tank—Liquid capacityl� ._gallons LengthJa_'�=' ._ Width.. Diameter__.__—._._-__ Depth_..%-r....... x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......... ........ Diameter__:_el-.__........_ Depth below inlet_. :5....-___ Total leaching area...a_a�....sq. ft. Z Other Distribution box /) Dosing tank (� ) Percolation Test Results Performed by.._/ � _�=!;''! '' z_ ____________________ Date_.��'_���:. �............ 0a Test Pit No. 1-------Z____.minutes per inch Depth of Test Pit.....�_T_.__.___ Depth to ground water--------- .............. 0-4 Test Pit No. 2.......?__._minutes per inch Depth of Test Pit..../2>`...... Depth to ground water_-_1_':;�_Z............ R'+ ............................................................................................................. Description of Soil-------'lG'�5--•-' = `'=-•----- ., i c✓ T®- --`�'>.�c; - 'Q'`1 -----------------•-------------------------- x W - --------------------------------------------------------------------------------•-------•-------------------------------------------------------=-------------------------------------....---•-•---- UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreemenun The dersigned agrees to install the aforedescri,b�`ndividual Sewage Disposal System in accordance with the provisions of TIT[E 5 of the State Sanitary Codes e undersigned further agrees not to place the system in operation until a Certificate of Compliance has been • sue by the boar health. N "0 Signed-- ; ---------- --- --..... •-- -- ..... .�-"�--� � _o ,�: Application Approved BY-- - ----------- ------- = ------- •: �� 5� �0� --- Date Application Disapproved for the following rea s:--------•--------•-----•--------------------------------------------------------------------•-•---------------- --••-•-------------------------------------------••--------....-------•------•------•-•-•--------------...------•--------•-----------------------.._..----------------•-------------------------•••-•---- - Date PermitNo..... ,Z..Q.•�_{..... -.-..... - Issued...............••---------------....-----•------•-_..... Date THE COMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH /rv..V.V... ......OF..... �. �V�-1�!.. .�.o .!I ���-............... Tntifirtt#r of Toutliftatt r TH.• S TO CER IFY, hat the Indiv al Sewage Disposal System constructed ( ) or Repaired ( ) /DQ J , by........ .../ .V l..r-. t .�?.�.1- ..F�. -- ----------------------- t..... 4�5 4, `Wt '.'A C ............. ------------- has been installed in accordance with the provisions of TI > of The S to Sanitary Cod . as scr' d in the application for Disposal Works Construction Permit No. __ __ .-�_ dated-__._ ��__ �---_--------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARDYPF HVA T H_ A&�e 3 1 No.06 •-•-- )� //��� Fy ............ uiupmsi 1 Wort (9ug ion �ernti# Permission hereby grantedv�__... - --• sue to Construct ( o� Repa• nn�;vi�� } � po al St at No... --._......_• � reet y as shown on the application for Disposal Works Construction Permit N \_ = bated________.___� _..-----•....................... ....... Board.of Health DATE. --- FORYI 1255 HO S & WARREN, INC., PUBLISHERS 'l `own L'10 ' wide l 13 '-n•`P'3' � 3 .,•Jay . f� • 'u3s � � i i4 a 3s.14 r M l,tGTo412C1 ,, ao c,pe �l ii.a' Z � Zo 11.2 iQa 7. � �' �. ) 2� 9�J2 ErfP. tP� Z, 3 N'? i 7 4 t v� o' 1 0 c 5 � ` oo d � 11 5 �7 10 l.0 S �CiI.PiS, r tC l r !� d tone 392 i 1•o / PowdPtlwan 547.62 40 ' wtap_ 0 i o M1 t Scale 1 " = 40 ' co. Date 3-6-8 7 I 60 ! aaerxevtt 2F v. 'f-!9 f7 2.s Att Cap e F—tea` /AjanaiA ('1;2. 02601 i 1�owJc-A,i.§n --- I S00 i No. bed—worm. 3 t (iamb aq e aAA'. �w S `7 ^ v -1 ! ! JO-tat ' x ' p i i.L eCchivi�j, area 30 W/2 1,6 tone C'apac�/ 3R2 pd a.z I ;/Mote: �tevat o;vs to& G let. S 9.6 9 l ;S ee tch. Ptcas o? 1-and in Cen --,w ,fie, Ma. ')ot Jauzd Ober i 'eiu:c a pc%cPJ. o� tad a, Jwwn on a plan made ¢ot C"hchf A and teco�zcled in bh 277 pq� 65. Ct,evati,oflA have been ad ju4 ted to wa-teA f ow'zd on tot. (u S Cj. S) j i G.te -7 ZZ-i)ZZ7Z-o -T ece HT7------ i i i feat pit4P-60 S 3 Ilcde 8-12-86 Va,te.t erzcoun teaed. /='etc. SIP 1 �7 2 14.? 12.tR n;.ed crl nsec iwt date acwul OF qrq ( e J MI E cr S E J TES°°� 2:g- f- vJ�•-e_� _ O: \cEALS�o� i i ACCESS COVERS MUST BE WITHIN 9" MINIMUM. MIN 2" OF PEASTONE 6" OF FINISH GRADE 6' MAXIMUM COVER OR FILTER FABRIC INVERT ELEVATIONS : DES I GN CR I TER I A : GENERAL NO TES : FIRST 2' TO INVERT OUT SEPTIC TANK: 96.0 DESIGN FLOW: 4'VENT WITH INVERT IN DI ST. BOX: 95.77 3 BEDROOMS AT I l0 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION BE LEVEL - CHARCOAL FILTER, 101.5 99.5 18" MIN INVERT OUT D I ST. BOX: 95.6 BEDROOM EQUALS 330 G.P.D. ~ OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4' DIAM PIPE 96•5 INVERT IN LEACH CHAMBER: 95.5 3/4" - 1 I/2" DIA. NO GARBAGE GRINDER a .'' 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS 96.0 95.6 H-20 o BOTTOM OF LEACH CHAMBER: 93.5 2' DOUBLE WASHED STONE GAS �/ g5.77 0 95.5 93.5 ADJUSTED GROUND WATER: N/A SET. SEE SITE PLAN. BAFFLE) SEPTIC TANK REQUIRED: 3 OUTLET 2-500 GAL LEACHING CHAMBERS OBSERVED GROUND WATER: N/A 330 G.P.D. X 200% - 660 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND EXISTING D-BOX W14' STONE AROUND. 12.8'w x 25.1 x 2'B BOTTOM OF TEST HOLE *2: 88.5 SEPTIC TANK PROVIDED: 1000 GAL. EXISTING .` MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1000 GAL H-20 CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6" CRUSHED STONE OR SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE ^ DESIGN PEkG RATE l 5 M l N/INCH PROFILE : NOT TO SCALE SOIL TEXTURAL CLASS - I 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT L OAD l NG RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED: 2-500 GAL LEACHING CHAMBERS W/4' STONE AROUND. A-471 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 471 S.F. x 0.74 - 348 G.P.D. APPROVED EQUAL. SOIL TEST P I T DA TA& 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED PRECAST CONCRETE OR APPROVED POLYETHYLENE. INDICATES _ 7� INDICATES BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER PERCOLATION = OBSERVED TEST - GROUNDWATER TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE TP Of TP s2 OUTLET. Pao53� 0. HORIZON TEXTURE COLOR 101.2 0' HORIZON TEXTURE COLOR 100.5 7. BEFORE CONSTRUCTION CALL "DIG-SAFE 309.44• FILL FILL I-888-DIG-SAFE AND THE LOCAL WATER DEPT. 12' - - - - - - - - - - - - - - - 100.2 20' - - - - - - - - - - - - - - - 98.8 FOR LOCATION OF UNDERGROUND UTILITIES. A LOAMY IOYR A LOAMY IOYR SAND 3/3 SAND 3/3 � \ 24' - - - - - - - - - - - - - - - 99.2 28 - - - - - - - - - - - - - - - 98.2 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE \WF 6 \ \ CB/SEAL FAD B SAND 5/6 LOAMY IOYR B SAND 5/6 LOAMY IOYR DES 1 GN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION \ 32' - - - - - - - - - - - - - - - 98.5" 36' - - - - - - - - - - - - - - - 97.5 OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE MED-COARSE IOYR MED-COARSE IOYR CONS TRUCT l ON l NSPECT I ON$. \ / �I SAND 6/6 C I SAND 6/6 GR.avFc '� 9. EXISTING CESSPOOL TO BE PUMPED DRY AND ep4,0 _\ WF 5 // NO WATER 90.2 144' NO WATER 88.5 / 1 I A RE,� / l ,/ // Q' ,/� I' f �� .��'(~- DATE:-MARCH 2I. 2017 1 \\ 1 5 r� . /+( } l ( l /01.4+� v TEST BY: STEPHEN HAAS 32 S• F• ` WITNESSED BY: DONALD DESMARAIS +99.2 BRB FND 9' PERC RATE: ! 2 MIN/INCH 12"OAK ,-•� � �Q , EX7�fi/N6 Io4 1 \ 1\ \\ I LEACIHING AREA ,1 2_500 GALLON I `\��� /"\ \ ��� 1 \\\ \ LEACHING CHAMBERS 1 � DE RN 1 1 1 1 \ BM. CORNER STEP 18' AK W/4' STONE AROUNb 9 i�I OF 4 I I 11 11 \\ i E )'ING EL 99.47 �/ �1 12'04K - / l0/.,) 1 \ I D EL(ING 3 a - -25 -....'.'. ': +- - -I_ L OCU �s I 1 I EC/( v;' VENT 1 N _ /02.6 tc TPrI /p ROUTE 1 4.:..... /0. 9S 5 � 0-BOX ., -- I WF 3 101. LOCUS MAP i I EXISTING PIT i SEPTIC TA 98.9 AREA VARIANCES REQUIRED : aK ONE TITLE 5. MAXIMUM FEASIBLE COMPLIANCE I I I I I I 1 1 \ > SECT ION 15.221:!71 GENERAL CONSTRUCT l ON REQUIREMENTS FOR ALL SYSTEM COMPONENTS 98.4 `* THE TOP OF ALL SYSTEM COMPONENTS SHALL BE NO DEEPER THAN 36' BELOW GRADE. 2 !i II 11 140 S 0 / _ \ A VAR 1 ANCE IS REQUIRED FOR THE SAS TO BE BETWEEN 3' AND 5' DEEP. f S � A'�1/ 4 \ //\ iYnr/ S E P T I C S Y S T E M D E S I ON •S47 1 I }I � I UP 963-9 ��, _ �i " !j 0 � l 12 POWDERHORN WAY . MAP l 70 . PARCEL 22 i 1 1 I � 1 1 1 1 I BARNSTASLE � CE7NTE_Rv1LLE � MA . 1 I LEGEND PREPARED FOR . WF I 11 ■ CB CONCRETE BOUND 2 s� -W WATER LINE y v ` ANDER SUN B I AZZOLA O HYDRANT -c GAS LINE SCALE : I - 20 APR I L 22 2017 OHW- OVER HEAD WIRES LIGHTPOST STEPHEN A . HAAS -E- UNDERGROUND ELECTRIC LINE -T- UNDERGROUND TELEPHONE LINE _ ENGINEERING , INC -CTV- UNDERGROUND CABLEVIS70N LINE / %= P . CD . B o x 16 /+ -F 40.4 SPOT ELEVATION // i��j'1 11��� S a u t h D n n i s MA O 2 6 6 O -.--.---40-••---- EXISTING CONTOUR 5 O 8 � 3 6 2-8 1 3 2 0 IO 20 40 40 PROPOSED CONTOUR JOB NO: 17-0/0