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HomeMy WebLinkAbout0009 PRINCE HINCKLEY ROAD - Health 9 primze Hinckley Road, Centerville :J391 0 1 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,,1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: (21" Fill in please: APPLICANT'S YOUR NAME/S: . /- CQ A 4 Ol61 P BUnS.pINESS YOUR HOME ADDRESS: c iAIC,-6� C ' TELEPHONE # Home Telephone Number MY OTZ '3 45 NAME OF CORPORATION NAME OF'NEW BUSINESS ,MJ5 I N N TYPE OF BUSINESS A41N IS THIS A HOME OCCUPATION? YES N ADDRESS OF BUSINESS, LN(' .. N>?/CI` — AR/PARCEL NUMBER. '-/ [Assessing] When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE 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 hasybee forme th er it re re ants that pertain to this type of business. MUST COMPLY WITH ALL u orized Signature* Hh7ARDOUS MATERIALS REGULATIONS 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, Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE NAME OF BUSINESS: IS PAW' 7_010 BUSINESS LOCATION: 9 FR i xACC— /4 IV E IQ6 Mv*519VIIZC INVENTORY MAILING ADDRESS: j®l,:3910 ?'I_�2 S 441� ae&Z TOTAL AMOUNT. TELEPHONE NUMBER: S®� 36��l Ojizf® CONTACT PERSON: e4'7I_S62 EMERGENCY CONTACT TELEPHONE NUMBER: MS SON SITE? TYPE OF BUSINESS: P,4(,V+I� INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer)_ lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids '/,^ A f (dry cleaners) 4CA V(� 1l 1 �1 _ 4E C_ V6#)LlCP(— Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS App I Staff's Initi ' 74k DO 0 1 et More saNring. ��� • � (L� �� � o More doing.' 65 INDEPENDENCE DRIVE HYANNIS, MA 02601 (508) 778-8948 261.2 00056 76887 02/2,1/11 11:34 AM CASHIER SELF CHECK OUT - SCOT56 025417691290 DC CO ALARM <A> 17.78 SALES TAX - TOTAL $18.89 XXXXXXXXXXXX3726 VISA 18.89 AUTH CODE 03594G/0562235 TA III 1111111141111 2612 56 76887 02/24/2011 8881 RETURN POLICY DEFINITIONS POLICY ID DAYS POLICY EXPIRES ON A 1 90 05/25/2011 THE HOME DEPOT RESERVES THE RIGHT TO 9 LIMIT / DENY RETURNS. PLEASE SEE THE RETURN POLICY SIGN IN STORES FOR DETAILS. GUARANTEED LOW PRICES LOOK FOR HUNDREDS OF LOWER, PRICES STOREWIDE dw9,„Il •,•.. ��cr;rxe�rrc�c���r�ex��rcx�rxx�;x�xX'x�cercArxvc�xxvc� ENTER FOR A C;IIAItiIe~:E kl TO WIN A $5 , 000 HOME DEPOT GIFT CARD ! �tiws _ a = Share Your Opinion With Us! Complete the brief survey about: your store visit 4, a and enter for a chance 1:o win at www.hrmedepot.com/opinion i F'ARTICIPE-: E-- UNA OPORTUNIDAD DE GANAR UNA TARJETA DE REGALO DE TFID DE $5 , 000 ! iComparta Su Opinion! Complete la breve . encuesta sobre su visita a la tienda y tenga la oportunidad de ganar en: www.homedepot.com/opinion tJs�r TD 156675 154119 Passwcar—cl 11124 154063 Entries must be entered by 03/26/2011. Entrants must be 18 or older to enter, See complete rules on Website. No purchase necessary. i TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out Owner D,&,A,,f I nl>6C Tenant Address 2 L©L L i A)6 /`l1/ Address Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities _ 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural n n p\ Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal �p 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms o Number of Vehicles All 2d ( Number of Persons Allowed (max) ! Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here ` 9 TOWN OF BARNSTABLE BOARD OF HEALTH �J ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date ��^ M �� I Time: In Out Owner �l�W w�- ,� Tenant Address � "'—' �^'� Address Compliance Remarks or Regulation# Yes O Recomme tions 2. Kitchen Facilities Approved: 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing r1/ 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms 3 Number of Vehicles Allowed (max) Number of Persons Allowed (max) -5 ----� Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here jt,. TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION �U ' V r Date _ ! Time: In out /6 Owner �l�G�ri,� f ^-�-�C Tenant1 Address G�� —� ,�.� Address Compliance Remarks or Regulation # Yes j,,A0 Recommen tions 2. Kitchen Facilities 0 3. Bathroom:Facilities 4. Water Supply 5. Hot Water Facilities n 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing IV 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition vr' Number of Bedrooms 3 Number of Vehicles Allowed (max) Number of Persons Allowed (max) -5 --�---� C . Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here ` TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date °Z l� Time: In 1 J Out Owner 1 ,��i Tenant r D e, Address 2 /�-� Address 0 T � Compli ce Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities _ (0 3. Bathroom Facilities p�ppr caf .� � l 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation r 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal -3.4- NZ— —7 — 17.Temporary Housing V oe 18. Driveway Width 19. Number of Tenants Observed ti j6ro ( a G4 PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) �_ L5 Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here � � Y LOCATION SEWA PERMIT NO.. VC Q VILLAGE t INSTALLER'S NAME & ADDRESS B UI,LDE R OR OWNER 6 / mew A.� DATE PERMIT ISSUED DATE COMPLIANCE ISSUED _�� _ � Q t � 1 ••---- Fizic ../4)............. THE COMMONWEALTH OF MASSACHUSETTS BOARD qF HEALTH ---OF....... .. ------ -------------------------------------- ` � Appliration -fur 43iu uottl Workfi Tonfitrurtiun Vanift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: p '`�_e.. ,l �L �1 �i�//1/ � 1� .... Z..." ��-`��---------•-------------------------................................ Location_Ad dre s or Lot No. Lcaner Address Installer Address Q Type of Building ��jj• Size Lot f�f_ -------Sq. feet U Dwelling—No. of Bedrooms_----__C ............................Expansion Attic ( ) Garbage Grinder qxa) aOther—Type of Building ____________________________ No. of persons-_______-________.__..._____ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - - W Design Flow................ `a Mons per person per day. Total dailyflow__________XlJ- gallons. WSeptic "lank f/ Liquid capacityr�" gallons Length................ Width................ Diameter---------------- Depth-_--______----- x Disposal Trench—N`o`_____________________ Widtll__________ ,yy-�� Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No-_______1____..___.. Diameter_�d_ ______�Depth belo inlet____________________ Total,leaching area------------------sq. ft. Z *Other Distribution box ( ) Dosing tank ( ) ®;_ "oe A a " Percolation Test Results Performed by-------------------------------------------------------------------------- Date_------------------------------------... a Test Pit No. L_______________minutes per inch Depth of Test Pit.................... Depth to ground water_--_____-_-___-__-_--.- �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ----- 4 � �• K 1� x Description of Soa.J_------ -- �i .l�'rd_----..:�Y��----�--=•--••--=�-�--'--�-��-- ----� �}r�,-----r•--• ----------•-n-------- --.. UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------__________-___-________--.. 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 underslgnsl further agrees not to place the system in operation until a Certificate of Compliance has been issIled by the board I health. .. Sig �A�.. 2 ... Date ` Application Approved By.' .. - ------ - ----- - ��° �� �� /L � Date Application Disapproved for the following reasons-------------------------------------------------•---------------------------------------------------------------- ------------------------•---------------------------.._.. ...........................................----------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date •••••••.•••.•••••••••••••••••••••••••••••••.••.•.••••••••••••••••.••••••••••••........................................ •�••.••� THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH � .............oF........_ .. .. .. . ............. ..........i.... Trrtifiratr of Tompliaurr THIS IS CE TI T e Individual Sewage Disposal System constructed ( or Repaired ( ) by G -- G� - has been installed in accordance with the provisions of Ar ' �X of The State Sanitary Code as described in the application for Disposal Works Construction Permit N --- ----------- /_�____ dated"....lX_'.�_....:c THE ISSUANCE OF THIS CERT9FICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... / /4 t ..... FEs......_..�r.......� THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH . .----------OF......../_ Gt, w F11 fs- rc. Appliration -for M_npoottl Vorkg Tonfitrnrtion Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address _ or Lot No. .......................................... ,Owner _ Address W '"1 r �- .� /r L'L-G_e_,7 / ��1i/E� / relic- /1/l LC S ......•.. - . •-----------------------•--------------------------_-__________________ _______________-•--•-------...............__....__•..... �._____.. Installer Address UType of Building Size Lot_5_._!, ."I-)-_____S feet Dwelling—No. of Bedrooms-------- ---------------------------------Expansion Attic ( ) Garbage Grinder (rfrr) aOther—Type of Building ____________________________ No. of persons.-.-____-.-._.______-___--__ Showers ( ) — Cafeteria ( ) Otherfixtures ------- -------------•--------------------------------------------•-------•-----------•----------------- - -- ------------------------ 31� Design Flow--------------_-5�____.._______------ gallons er erson er da Total dai] flow_-------------------_-_-_-_.-__-. . .------- W P P P Y Y gallons. WSeptic Tank�Liquid capacity.. gallons Length---------------- Width--------........ Diameter__._.-..-..----- Depth-------------_. x Disposal Trench—No..................... Width------------ _: 9 Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No-___-_-__/_._...___ Diameter__"2�...' epth below. inlet____________________ Total leaching area..----..--._.-____sq. ft. z Other Distribution box ( ) Dosing tank ( ) d 6- �-6� %- - / y` �1& aPercolation Test Results Performed bY----------------------------------------------------...................... Date--•---------------------------------.... Test Pit No. 1----------------minutes per inch Depth of Test Pit-.------------------ Depth to ground water...---.--.-._-.-_-.---. G� Test Pit No. 2................minutes per/ inch Depth of Test Pit._-___--_-___._.__-_ Depth to ground tio ;; --------- -- C ....... .: water...t-.---____---_-------. +/r f Description of Soil / -- --- - ---- --- Z ----­---------- --- -------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable___-----------____----------------------------------------------------------------__---------- -------------------------------------------------------- ______________•--------•-----------___------------------------------•--------•------------------- -------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board ofIhealth. / j ` r Sign ('. `J -+�', c/-f �" - 7� f Date Application Approved By._C.� f � `y 1 /�7C �'-'- / Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ ---------•-• ..__...••-••••-------•--•-•----••--------•-.....•-----------------------•...----------•------------........------•_-•-•- Date PermitNo......................................................... Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rtifiratr of 011kompliatta THIS IS ,'� CE %TI �Tlt%i�e Individual Sewage Disposal System constructed ( or Repaired b3' *i �, - -------- •- --• ----- -------- •..... ~ Inhas been installed in accordance with the provisions of of The S to Sanitary Code as described in he application for Disposal Works Construction Permit No. ...G__� dated.._._._ _-.�_Z. ..._..__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................---------------------------------------- Inspector............................................................... ................... THE COMMONWEALTH OF MASSACHUSETTS !, l BOARD OF4 HEALTH' JY .............:..... OF............4. .. 1+�/L. �..... _..� No. / ••... FEE--- ............... �i��o�ttlV Permission i hereby granted. ------ ' f to Construct or R ( n . n ivi ual Sege DisposagS 'tempat No._.L�t-�p GtIL 6�! � .. c._- ` S�tree ^�� as shown on the application for Disposal Works Construction Pero_______ ______ Dt�' _._- _--...____..._....__._..._._________ •.-.���' DATE. _�_'.?__� ao d of Health / FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �� / i ems. Go _ f 'Al _ 35 f �f' Fitt Lt •� tx.' � rAoVit FD �� SctaLttI � C6tZTt1=Y 'l"r•-tAT' Tl-��=. ��v+�p�T1�W S�Gw�.l PLr4�1 R�=�=c.R�.�.1C� ` Ntr1:i`a+�1 G ii'1.�5 W ITN TWG 5l DE Lit-1f=- AW SETKh+C ICA { C-Q cSiiZtA/�C►-4 j'S CO'- TNi� /� l c w U GF' L� +r�J ST/y _J�.. � P LA W C:3EL. S CV.. Z 4 I�A'tC r t2E615 rX---Zaa LA Wr-> SUZVaYO V-c'. ` I-At'S t7l_Aw iS "UT 15445i✓v AIQ OSTSV-VXL.LG o lvCAS�� %445'QL;AAa%-J -UOZVZ.-{ <- TtiC 5+4c,%jLx- At-' "LtCA."-r t IM1 t�.T" $ l'•.i?t� �u Z7�t�RM��t� LG'T Ll1�lL�i '" A PERMIj SEW A �--- AT I.LAGE �. AppitESS NA*E INSY A LLER'S t OWNER OR 1 sUtLpER I s:/ P ER1411 ISSN Ep 4A E a-1 DAt E COIAPL C 1 AN E ISSVED --01 i 7Y o„ r� C t Commonwealth of Massachusetts IN I Executive Office of Environmental Affairs Dept. of Environmental Protection ,Jolm Grad One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket,.MA 02536 (508)564-6813 WILLIAM F.WELD Governor 2 ARGEO PAUL CELLUCCI N /d� Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A � r CERTIFICATION 9 Prince Hinckley Rd.Centerville 02632 Address of owner: �m Property Address: y dQ Date of Inspection: 2/26198 (If different) 1 ; Name of Inspector: John Oraci Mrs.Cowhey �Jy 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) (P �� -4 Company Name,Address and Telephone Number: ' CERTIFICATION STATEMENT 1 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 sewage disposal systems. The system: This Inspection Is based on criteria defined In TftI9 V x Passes code 310 CMR%3w.my findings are of how the system is _ Conditionally P ses performing at the time of the Inspection.My Inspection does not imply any warranty or guarantee of the longevity of the _ Needs urther valuation By the Local Approving Authority septic system and any of its components useful ire. Fails Inspector's Signature: Date: 2126198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: , One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,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 Colttpllance(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 conforming septic tank as approved by the Board of Health. (revised 007197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 ♦Y 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Prince Hinckley Rd.Centerville D2632 Owner: Mrs.Cowhey Date of Inspection:2126199 _ Sew,aae backup or.breakout or high Static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet or 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination 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 in 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 cesspool. SAS is in hydraulic failure. (revleed OLrt718T1 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Prince Hinckley Rd.Centerville 02532 Owner: Mrs.Cowhey Date of Inspection:2126199 D]SYSTEM FAILS(continued) Yes No 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). Numbers 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 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no — acceptable water quality analysis. 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"as to each of the following: The following criteria apply to large systems in addition to the criteria: 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 owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revlsed 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 9 Prince Hinckley Rd.Centerville e2632 Owner: Mrs.Cowhey Date of Inspection:2126198 Check,if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System, have been located on the site. x 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. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable))15.302(3)(b)) (revleed MUM?) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 Prince Hinckley Rd.Centerville 02632 Owner: Mrs.Cowhey Date of Inspection:2126199 FLOW CONDITIONS RESIDENTIAL: Design slow: � g•p•d/bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 1 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: nia COMMERCIAL/INDUSTRIAL: Type.of establishment: nla Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nra Last date of occupancy: We OTHER:(Describe) nfa Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was pumped t•2 years ago. System pumped as part of inspection:(yes or no)Na If yes,volume pumped:0 gallons Reason for pumping: nla TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(if known)and source Information: 20 years Sewage odors detected when arriving at the site:(yes or no) No I (revised 0412707) i S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Prince Hinckley Rd.Centerville 02632 Owner: Mrs.Cowhey Date of Inspection:2/26199 SEPTIC TANK: x (locate on site plan) Depth below grade:8" Material of construction:x concreate_metal_FRP_Polyethylene—other(explain) If tank is metal, list age we . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: t_8V^H6'7"w4•l0" Sludge depth:"' Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:0 How dimensions were determined: measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound and functloning properly.Recommend pumping every one to two years. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:nfa Distance from bottom of scum to bottom of outlet tee or baffle:rda Date of last pumping;,, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: 12-, Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line!— Diameter: 4" Qmments: (conditions of joints,venting,evidence of leakage,etc.) I (revlsed 04127)97) IL SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Prince Hinckley Rd.Centerville 02632 Owner: Mrs.Cowhey Date of Inspection:2126198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: rda Capacity: rda gallons Design flow: rda allons/day Alarm level:_nre Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rds DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_yer, Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) rda (revised 0412797) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 Prince Hinckley Rd.Centerville 02632 Owner: Mrs.Cowhey Date of Inspection:2126199 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits,number: 1A00 gallon leach pit leaching chambers, number:nla leaching galleries,number: nla leaching trenches,number,length: rda leaching fields,number,dimensions:nla overflow cesspool,number:nla Alternate system: rda Name of Technology._rda Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Leach ptt and all components are structurally sound and functioning property.System has 2'or water in IL CESSPOOLS: (locate on site plan) Number and configuration: I've Depth-top of liquid to inlet invert: rda Depth of solids layer: rda Depth of scum layer: Na Dimensions of cesspool: nla Materials of construction: rda Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) We Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda PRIVY: (locate on site plan) Materials of construction: Ne Dimensions: Iva Depth of solids: rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rds (revised 04127)97) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 9 Prince Hinckley Rd.Centerville 02632 Mrs.Cowhey 2126198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 51 `14 � Pay ! of 10 (rnvlosd OW27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 9 Prince Hinckley Rd.Centerville 02032 Mrs.Cowhey 2126199 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts (revised04)27197) Page 10 of 10