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Home My WebLink About0191 STONEY CLIFF ROAD - Health 191 Stoney G iff Road Centerville A= 190 145 INISMEA No. H163OR UPC 10259 smead.com • Made in USA ��cyct, 2J m nTOWN BARNSTABLE ,OCATION �j �Idrw� (o r�W YI SEWAGE# 15fe`40y% ILLAGE rw��'lQ ASSESSOR'S MAP&PARCEL W�- �S NAME&PHONE NO. � SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) t t (size) 10W Rd NO.OF BEDROOMS nn OWNER ar'o- ,n PERMIT DATE: CTRffftlA DATE: I a�IGfo 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 FURNISHED BY Stoney Cliff Ac of 43 9 ` A 27 30 68 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $40.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS 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, 15' FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. Fill in please: Date: / ar h� r APPLICANT'S NAME: VYl YOUR HOME ADDRESS: f VY(9t � ^ 7Qt, h `. - J BUSINESS TELEPHONE # HOME TELELPHONE #: EIN NAME OF CORPORATION: rd MFID # NAME OF NEW BUSINESS C—CjVACQ-IQd TYPE OF BUSINESSRTwLe IS THIS A HOME OCCUPATION? YES N . ADDRESS OF BUSINESS MAP/PARCEL NUMBER I�O - I`�S (Assessing). When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of Barnstable. This form is to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth Rd. b Main Street) to make sure you have the appropriate permits and licenses required to legalhy operate your business in 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 h s i fo med of the permit requirements that pertain to this type of business. Authorized Signature** MUST,,OMPLY WITH ALL COMMENTS: HAZARDOUS MATERIALS 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** TOWN OF BARNSTABLE Date:10/ 5 / TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: q S INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: ywyi EMERGENCY CONTACT TELEPHONE NUM R: (g MSDS ON SITE? TYPE OF BUSINESS: 4WYLL 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) pu/vti�s Hydraulic fluid (including brake fluid) Refrigerants ZNEW r OilsZUS �'q��,� IQ�S Pesticides ® 00 (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 3 C@,i�KlfS 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 I jitWk ay U-35 Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners I C 411 q\( ( S Q (including carbon tetrachloride) "EW YUSED 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 tees iky"V Lj0_ Laundry soil &stain removers (including bleach) IeSS Navl I T((Sv\ Spot removers&cleaning fluids (dry cleaners) ther cleaning solvents lee S [ VIL�VlBug and tar removers (� (' 1,Q1/ V'Windshield wash a.��[a Y__ --� WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials I_ COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t y�e TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 191 Stoney Cliff Road Centerville MA 02632 Owner's Name: David Fortman Owner's Address: 6836 North Ridge Bl. Chicago IL 60645 . Date of Inspection: November 28,2006 Job#06-312 Name of Inspector: PATRICK M.O'CONNELL ` 1 c,i to Company Name: SEPTIC INSPECTION SERVICES CO. F Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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,. P Y ?n rrrrr; approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: OF Passes Conditionally Passes 1 PAThIC :G Needs Further Evaluation b the Local Approving Authority ` Y PP g tY Fai 0 Ins ' L� ec � .�p tor's Signature: on Date: 11/28/06 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: Tank not in need of pumping at this time,leaching pit was empty at time of inspection. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 191 Stoney Cliff Road,Centerville Owner: David Fortman Date of Inspection: November 28,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 191 Stoney Cliff Road,Centerville Owner: David Fortman Date of Inspection: November 28,2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for 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: Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 191 Stoney Cliff Road,Centerville Owner: David Fortman Date of Inspection: November 28,2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] _No_(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 will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 191 Stoney Cliff Road,Centerville Owner: David Fortman Date of Inspection: November 28,2006 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _ _X Were any of the system components pumped out in the previous two weeks? _ _X_ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X _ 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 _X_ _ Existing information.For example,a plan at the Board of Health. _X_ _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 191 Stoney Cliff Road,Centerville Owner: David Fortman Date of Inspection: November 28,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents:0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):No Water meter readings, if available(last 2 years usage(gpd)): Two years total: 102,000 gal.=139 gpd. Sump pump(yes or no): No Last date of occupancy: unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/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: Last pumped 7/1/99 Source of information: Barnstable WPC Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 8/10/83 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 191 Stoney Cliff Road,Centerville Owner: David Fortman Date of Inspection: November 28,2006 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: - Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_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:8.5'long x 5.2'wide—1000 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" 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: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank has liquid only, no solids. Liquid level at bottom of outlet invert and tees are intact GREASE TRAP: No (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.): Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 191 Stoney Cliff Road,Centerville Owner: David Fortman Date of Inspection: November 28,2006 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No solids or hieh stains present. PUMP CHAMBER: No (locate 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.): I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 191 Stoney Cliff Road,Centerville Owner: David Fortman Date of Inspection: November 28,2006 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit. _leaching chambers,number: leaching galleries,number: _leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Leaching pit empty at time of inspection high stain lines indicate 4-5"of effective leaching CESSPOOLS: No (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.): PRIVY: No (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.): ' Page 10 of 11 e OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 191 Stoney Cliff Road,Centerville Owner: David Fortman Date of Inspection: November 28,2006 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. Stoney Cliff 43 I�+• 27 30 68 Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 191 Stoney Cliff Road,Centerville Owner: David Fortman Date of Inspection: November 28,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 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) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el 30 and topo map shows property at el.50. . �•�. TOWN OF BARNSTABLE Li4CATION L --irn if SEWAGE # ' -)--4D"`b VIILLAGE.C�f ulutj ASSESSOR'S MAP & LOT f INSTALLER'S NAME & PHONE NO. ��`� % 8, SEPTIC TANK CAPACITY U 1 LEACHING FACILITY:(type) r { .(size) r NO. OF BEDROOMS PRIVATE WELL OR P BLI WATER BUILDER OR OWNER � < '°�.,' ' DATE,PERMIT ISSUED: t � g DATE COMPLIANCE ISSUED: VARIANCE GRANTED: .Yes No 4' No...A:---YAO Fss.... C ...::...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE /o - Y,3 Vptfralfwt or Di!ipwial Worlui Towitrurtinn Prrmit Application is hereby made for a Permit to Construct ( ) or -Repair an Individual Sewage Disposal Syst at: ( U 66 WL tt \d-d--r-•e•s--- `l . 2` � ......-•.. ...............•.-4 • ` ' � .. wncr 90 JA .................................-..........Installer Address UType of Building Size Lot.:..........................Sq. feet Dwelling— No. of Bedrooms---------3..............................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type"of Building ............................ No. of persons--:--_-.------____---_---. Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... . . Design Flow............................................gallons per person per day. Total daily flow............................................gallons. ,:4 Septic Tank-Liquid capacity/Po gallons Length---------------- Width................ Diameter_............. Depth................ Disposal Trench--No- -------------------- Width. --------------- Total Length_.___ ... 5t....�Tot I leaching area....................sq. ft. 3 Seepage Pit No. ............. Diameter---�, ------------ Depth below inlet......J-P.�otal leaching area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. ]................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 water........................ -------------------------------------------------------------------•----........._.----•--•-------..------------------ •------------- -............ . ODescription of Soil-•---------------------------------•----•--•---•-----•-•------•-•------•---•--------------------------...............-----------------•--•--................------...... V ----------------------------•------------•-------------- W ---------------------------•-----...------...............-----------•---.._..--------------...........................- -------•-----•---------------------- U Nature of Repairs o 1 eration —Answ when ap lica le._-_----- _. ..... ...� .,r..........!''"f� �n � ° - -. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been u by the board of health. �� Signed ... . . ................................ ... ............... ........ ......... ................. Application Approved By .............t ...�..:L ...... ......... .... p...1.....3 Date Application Disapproved for the following reasons: .... ................ . ...................... ...... ...................................................... .......................................................... . .................. . . ----- ------------------------------------------............-------------------------- -- . .............................. Dare tPermit No. Issued .................................................................... Date �� w-�--�.�...-.-�w:+t....�..ss.(rt._:---..--•a�;;n-�..-Y.�+.'�,�.�.y-.-....�...-'--r•-..r�`.+�....-.xl:.�--y.,;-_,,..,xy�....�........�...r:,,,�,f�,+,nr, No...�2-....,10 /FEB..... '�........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE «< Appliratinu for Dirivn!ial Wnrkii Cnnnitrnr#inn Iteriftit Application is hereby made for a Permit to Construct ( ) or Repair K an Individual Sewage Disposal System at ........�' ...STr��` r..-± F :. ice.•- _ . - Loa liar -1\ddr•ss ------ ... E-----;--�'�-- ' _: a ��- Grp%lam- �n� -.C-. .j i�L�^ o,.ner -_ ------ ---......\ ndd e Installer Address Type of Building Size Lot.................... Sq. feet Dwelling— No. of Bedrooms........ -------------------_-----Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ......................-'. No. ,of`'`ersons________-_-.----.--...______ Showers — pr YP g ----• _, l? � ( ) Cafeteria124 ( ) Otherfixtures .. ---------------------------------------- -----------------•-------------.--.._...-----..-.---......... W Design Flow.....................................:. ..lgallons perr-person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity .gaI )ns Length-----------_--- Width._.____------__. Diameter................ Depth................ x Disposal Trench--No. ............!._...1 Width__/....._.__..!..:Total Length.__...__.y Total leaching area....................sq. ft. Seepage Pit No.--.I- ---- --_.- Diameter___ ____________ Depth below inlet-1.-.-._.�.__LlTotal leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by�...........................•._.-.---._____-.___.--.____--.-._---_------ Date........................................ Test Pit No. I................minutes per inch Depth of Test.-Pit.................... Depth to ground water........................ GZ4 Test Pit No. 2................minutes per inch Depth,of Te t/Pit._-_____...._....... Depth to ground water........................ ----------------------------------••----•-•.---•••--•---..... Descriptionof Soil --- -------------•---........----..-••----•-----------••--------•-----•-----...----•-----•-•••---••--...-•-••-•---•-•-•--....._.. v ..................•----•-•-••---•-----•....---•-----.._..------...... --------'.-•--------- -------......------......---------------•-------•-------•--------..............................---...... ----------------------------------------- -------------------------=----------------•=•.....--••-----f----------------------------------------------------------- ....c..� Nature of Repairs or Alterations—Answer when applicable._.__.___ tis. < . l v..... U P �q ,�,' l .......'Nf\ fly-� ..........f_11 1+�� - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issueby the board of health. Signedl �!/. ........................................ .. ........ to Application Approved B .�... Q....../ ..-... ....... PP PP Y ....... - . �. - 3 Date Application Disapproved for the following reasons: ........................ .. . ..... .. .................................................................. ........................ ..................................... . . ................... ................................................................ ........ ........................................ q Date PermitNo. . ....0 _ O .)o..................... Issued ..................... ..............-------- ............ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Tampltttnce Y /_ /ATO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (k ) THIS IS at .........pj..f........- ......�. / - �' �! ,t.--- --�°�...... ......._._ .77Z /�-�.......�....b1 .1 .............. has been installed In accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ----j"°._�------......_ ...... dated ........................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................._ ....'...�. -�....?......_.. - _._... Inspector .............._.........................1................ ... --.............. -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH QQ� TOWN OF BARNSTABLE No....l....:3-.y .C) FEE... 0............... DispnnttV1LA__6_,eV orkiiTonotrudinn Permit Yg Permission is hereb ranted........... -------- -w_-G>--7-X L �. C ...•-•--•-••.................. to Construct ( ) or Repair (x) an Individual Sewage DDisp sal System _ /�jJ ,�Q at No.--•--- ------- 3�, 1 ` 1- C----•- �` ScT«c C �L !.G.!...._/.L_.... as shown on the application for Disposal Works Construction Permit No15.,7. _,)Z? Dated........................................... ---,,� ---------------------------------------------------------- q� Board of Health DATE ^! 4 -----------------------•------------•--•--•- ��V// FORM 36508 HOBBS R WARREN.INC..PUBLISHERS