Loading...
HomeMy WebLinkAbout0358 STRAWBERRY HILL ROAD - Health 358 Strawberry Hill Road Centerville A = 248 — 133 S M E A D ft 2-1MOR UPC IM4 .mud-ma • wft in UM (MOTAINN ay8- 133 Commonwealth of Massachusetts �n ,,p Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road , Property Address Keith Field Owner Owner's Name information is Centerville ✓ Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information s/# NS34 on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Q Company Address Sandwich Ma 02563 City/Town State Zip Code «raa (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. 0 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey Digitally signed by Brett Hickey Date:202o.o5.2012:as:45-oa•oo 5-12-2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System/•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 358 Strawberry Hill Road Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection j C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The system was in working order at the time of inspection. The tank was pumped after inspection for maintenance. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form ~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road Property Address Keith Field ` Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts �p Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road Property Address r I Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 ti. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 18 _ c Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road v� Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (Cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ O Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 ' Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- _ 10,000 gpd. ❑ O 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc:rev.,726/2018: Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page of 18 Commonwealth of Massachusetts �m ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I . 358 Strawberry Hill Road Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ El Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? n ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ El 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: 0 ❑ Existing information. For example, a plan at the Board of Health. 0 ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 358 Strawberry Hill Road u Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: No design plans 3 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA Description: No design plans or permits were available at Board of Health. Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes rol No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes El No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes Q No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2019- 46,000gallons 2018- 35,000gallons Sump pump? ❑ Yes ❑■ No Last date of occupancy: currentDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 16 i c Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): i 3. Pumping Records: Source of information: Owner- last pumped 3 years ago Was system pumped as part of the inspection? ❑■ Yes ❑ No 1000 If yes, volume pumped: gallons How was quantity pumped determined? tank size Reason for pumping: maintenance after inspection t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts �M Title 5 Official Inspection Form +' 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road Property Address Keith Field Owner Owner's Name information is Centerville required for every Ma 02632 5-12-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1995 per original asbuilt Were sewage odors detected when arriving at the site? ❑ Yes ❑Q No 5. Building Sewer(locate on site plan): Depth below grade: 1'4" feet Material of construction: ❑ cast iron 0 40 PVC ❑other(explain): Distance from private water supply well or suction line: Town Water feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i, �1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road u'= Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 411 Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) • I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 000gallons 10If Sludge depth: 26" Distance from top of sludge to bottom of outlet tee or baffle 311 Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 14" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank was pumped after inspection for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form 1a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road v Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: . gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u� 358 Strawberry Hill Road Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert 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.): The d-box was in working order at the time of inspection. ' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road v Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA If pumps or alarms are not in working order, system is a conditional pass. I 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: (1)6'x6'pit w/2'of stone El leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: - t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts �s ,ip Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Pit was 1/2 full when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts �9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road V Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road Property Address Keith Field Owner Owner's.Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately TOwty OP ia^awSTA,►L 3 Lr Az9ott rS S rc.. �r.:l�; r r7,s sE'WAG8 'VILLAGE .� ASSESSOR'S MAP& LtJ't���"^ er�J4\�i� INS7ALLEA 8 MAME& PH+DtVIE AIi. k 7�C'= 7Jyy SRrTICTANX CAPACITY LEACHM.G PACIL12Ydrype} SLJs tir_$ c L(cixe3: 3 a S iI NO.OP 8FDR.0OM3* PRIVjTE WELL 0p, f+t7$LIt»WXTBR�r v i] DATE VARkArT ISSURG DATE COJ&PLjAr4CE'IssUED.1. Y:ARtJ ACE GR.ANTEXh AA AT, 1^;A f/L tQ'1C 3 COX J y r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts �v pTitle 5 Official Inspection Form 15 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 358 Strawberry Hill Road v Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope ❑■ Surface water Check cellar Shallow wells Estimated depth to high ground water: No GW 5' below SAS'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If,checked, date of design plan reviewed: Date El Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property sits high in elevation. USGS topo maps were used to determine ground water is greater that 5' below SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 II c Commonwealth of Massachusetts �n Title 5 Official Inspection Fora Ilk Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 358 Strawberry Hill Road Property Address Keith Field Owner Owner's Name information is Centerville Ma 02632 5-12-2020 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. ❑Q B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed �■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included r , t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal Syr ern Form NOt for Voluntary Assessments Property Address Ow vier 5 ner's Name _.._©� r( r� ��CSC✓r/� r;.�°I 's information �_ required for every _ �iC y+ !/'//�` l �� `� d :.:_. page- State Ylp Code Date of[ spin tion Inspection results must be submitted on this form. Inspection forms may not be altered in any way Please see completeness checklist at the end of the form. Impooutf mr. A. General Information Bing out forms C� Y 2 on the corrQuter, �J use only the tab 1. Inspector. key to move your cursor- et not use the return key, Name of Inspector -- - LC/f/4// company Name ConpanyAddress� t✓1tylTown rO ZO Code Telephone tuber License Number O` B. Certification 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 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 41nsr's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of i0,000.gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only Oescribes 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. t5ns•3M 3 U to Trtle5of8aal IrspecknForm Subsriface eDisposal S)stem•Page 1of17 r Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disp"I System Form -Not for Voluntary Assessments Roperty Address / Owner C)wner's Name C� ov1St?YI/ information is /' / required for every c_-2v-ko'v/1���page. Cty/Town ���2d State C Zpe D �npec KCfio� Ot D a� JS Inspection Summary: Check A,B,C,D or E/a/wayscomplete all of Section D A) System saes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes%."no"or"not determined"(Y,.N, ND) fur the following statements. If"not determined,"please ex0ain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y N ❑ ND(Explain below): a tars-3n Title 5Official Inspection F am Subsurface Seviege Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form .Not for Voluntary Assessments Property Address Ow n C o�rServc,� information is Owner's Name / required for every �2vi rv� e A4 1-0 a$ page. 5�-frown State Zip Code Date 6f lnsp6ction B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps%alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): 1 ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. 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 mannerwhich 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 t5ns 3N3 Tile 50friciallrLspecton Form SubgWam Sewage QispcsalSptem•Pge3cf17 t 1 � Com monwea Ith of Ma ssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner infonnabon is Ow ner's Name ��� paa4ge edforevey en 4e✓v1 � ;ZpCod:�:: o8 /j(�y/Town Date f Inspection B. Certification (corn.) 2• System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fbrm. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ � Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool E] Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6'below invert or available volume is less than day flow Mrs•3ry 3 Title s offiael kspeafian Form Subste808 SOYMO Disposal Slstem•Page 4017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not //for Voluntary Assessments Property Address Ow ner o vase✓r/�, information is O,v ner's Name / 6 requeed for every (�Gov► ��< a page. Qtyltown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ Er""— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or / tributary to a surface water supply. ❑ L�/ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ul 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 fleet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered A copy of the analysis and chain of custody must be attached to this form.] ❑ �, The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or'no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"'Yes'to any question in Section E the system is considered a significant threat, or answered `yes"in Section D above the large system has failed. The owner or operator of.any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3M3 Titie5 Official Inspection Form SubstrfawSmVe Disposal Sygem•Page5of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary//Assessments / Property Address CovlSerl/� ON ner ON ner's Name information is Ce /_ //1ALrequQed#orevey el Ile- vi /' r' page. CttylTown State _ Zip Code We of Ins ion C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ umping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? Xs the system received normal flows in the previous two week period? ve large volumes of water been introduced to the system recently or as part of inspection? re as built plans of the system obtained and examined?(If they were not available note as WA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? �❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: �❑ Existinginformation. For example, 'T 1� p , a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 330 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): tore•3M 3 Title 50ffidel Inspection Form Subsurface Sexage olsposal System-Page Sot 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l w(�2�1� Property Address QN ner O,v ner's Name information is required for every 2� `�/ A//T 0'J&30� /0 a8 page. Gtty/rown State Zip Code Date oVftpecbon D. System Information Description: /Dd . 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes E Noo Seasonal use? ❑ Yes a No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? A/❑ es No /r Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 1.5.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15rs-3h3 Title 6Official Inspection Form Subsulaos Sewage Disposal Sygam•F29e 7of 17 Commonwealfti of Massachusefts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -/Not for Voluntary Assessments ) JSF Sl (a'✓b-e(�' 91// �oC Property Address Ca 6� ON ner ON ner's Name information is /O o?$ I/- required for every GG'0" ""' ✓i Ile- page. 6 �� Cityfrown State Zip Code Date pf Inspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of inibrmation: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, wiume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S m: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): tsris.3M 3 TiOe 5 official Inepeetion Form substsface sewage Dispow system•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �35� �5����,,���� /J// PC) Property Address OVv ner o''1�P/VC, information is Ow nees Name required for every Po #f e 6o16302- /o Page. Rown /0 State Zip Code a of Inspection D. System Information (cons.) Approximate age of all components, date installed(if own)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 3 No Building Sewer(locate on site plan): Depth below grade: _ feet M e construction�4O cast iron PVC El other(explain): 1 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: /C feet Materi construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate ❑ Yes El No Dimensions: Sludge depth: Sns•3M 3 Title5offiaallnspecfionFom[Subsurface Sewage Disposal System•PNe9of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Plot//for Voluntary Assessments �-Y ��✓hey� ,�� Property Address -� Ow ner �o�lSPtit/ot information is Owner's Name requiredforevery GQvr yI/Ile 3d- AD )9 1s) page. Cdy/Town State Zip Code Date Inspection D. System Information (corn.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness A/V �C C.f yy 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? �-/ �L Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): L4 C/ Gtic/ V7 00C-// _ �OvC ,�10✓1 � Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15rs•3f13 TitleSOfficlal InspecfimFam:SubsurfaceSeameDisposd SYSWm•Page 10d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not ibr Voluntary Assessments Property Address 49 oose��� CW ner Cw ne's Name /� // -1 equ ed oreevery (�Qcn f�l/6G1� /¢ ©db to page. Citylrown state Zip Code Date of Inspection D. System Information (cons) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5m.3M3 Tide50ifidel I sperknFomc Subwface SevMeDieposel System-Page 11 of 17 F,a i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address ow ner '0 h Se V infOrnstion is owner's Name required C2vt (/! page Page• Cdy/Town State ip Code Date D. System Information (cont.) of pection Distribution Box (f present must be opened) (locate on site plan): 1 - Depth of liquid level above outlet invert z1--vet, 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.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t9ns•W3 TiW50f5cial InspeotionFomt Subsurface SevrdgeDisposal SpWm•Page 12 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property S7-41,/eV; Ow ner �'►S2 /(/� infomtation is Owner's Na Addressme __II�� required for every ��7�✓ page. CSt own State Z'1 Code Date of pection D. System Information (corn.) //�� // � f� Type. 6Yb leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): O off A/0 C,- 114 Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No tans•3113 Tiile6Official i spactitnForm Subsuface Savage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurrace Sewage Disposal System Form -Not for Voluntary Assessments 25e '-Act wL8r All 0R'O—W-ty Address Ow ner �o-t,S'ev infonnation is Owner's Name pa required for every C2 y2v A �/� U�G� /� lnspectlon__ �ty/Town StateZip Code Date®. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ns•3M3 Title50ffiael lnspectlanFomt Subsurface Sewage Disposal System•Page 14 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurrace Sewage DisposalSystem Form -blot/for Voluntary Assessments J � �¢lcc �✓u� e✓.^ /Ti l� �� Property Address Ow ner C o v's2✓!✓c� inform9lon is ON ner's Name page.edforevery Ce✓t (��a lv a S page. City/Town State Zip Code l7rate of In D. System Information (cont.) pectbn Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least rmanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately B � 3 a _ e" 1141 - d 7 Mr. 3113 Title 50fficial Inspection Fvm Subsurface Sexage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection a Di p n Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments RoPertyAddress Q" Owners Name "'Se✓vc�b quiredifo'e page. dforevery (��� page. City/Town I/I/6 State —� Date ofv; a 8 ®• System Information (cost.) pecW Site Exam. ❑ Check Slope ❑ Surface water T%° ,dp ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. Please indicate all methods used to determine the high ground water ele vation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: ❑ Date ' rObserved site(abutting property/observation hole within 150 feet of SAS) [�" Checked local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: U S Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ns•3l'13 Title5Official Inspection Fa m subsurface sewageoispwa SYMM•Page 16 at 17 N Commonweaf h of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposalsystem Form-Not for voluntary Assessments // RoPerly Address ON nor 0OSLO/� � infomwon is Owner's t�aene requffedforevey Vol ?d PaSe City/Town E. Report Com es pletens Checkiiste cove S _ Ins ion Summary:A, B, C, D, or E check ed Ins ectW Summary D(System Failure Criteria Applicable to All Systems)completed stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file �•ans TJGe5Of C9d IMPSOdW FQ=SuOctffeCe SerageDisposel SyWM.p%e 17 of 17 ,,` I 5/8/2020 ShowAsbuilt(1700x2800) TOWN OF BARNSTABLE LO ATION MT.�1r[-��x r�lNill Aid SEWAGE# VILLAGE CeA�CrU\\lP ASCCSE__SSOR'S INSTALLER'S NAME&PHONE NO. --�(_UA II SEPTIC TANK CAPACITY I.(' )U (Z^k C') Q c->X.?1{ULo LEACHING FACILITY-(type) Lx(, 2, (size) Li � NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER IPJ 6 BUILDER OR OWNER U^C,�s(x,r(A C(&W f Vcl. DATE PERMIT ISSUED: ,}1G1 1"A DATE COMPLIANCE ISSUED: JII(r I5S VARIANCE GRANTED: Yes No �csuJ CICG✓iU� I o Qox 3 Q 10 ai I S ` kv PiA y4 �u c tcw w's �►� 13 to F;� p _ C 4u ctCwwV} 1�,$ https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=248133&sq=1 1/1 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: N/ I Fill in please: APPLICANT'S YOUR NAME/S: e, 'eI Ggn�eCV�IIG BUSINESS YOUR HOME ADDRESS: 35` St{Awbe(�•c wit lIl p� Y 11t�i " ',.• aJ z,il i� rir _TELEPHONE # Home Telephone Number kilt,7µ,�rrr ro Y+ a. - Email Address: NAME,OF'CORPO.RATION:'' NAME OF NEW'BUSINESS (• .�`'I +� bf Neaten TYPE OF BUSINESS LAM IS.THIS A HOME.OCCUPATION?.' YES NO MAP PARCEL NUMBER (Assessing) ADDRESS OF BUSINESS Sdfa.rbe<< ;Il �� Z-P�1 you must do in order to be in compliance with the rules and regulations of the Town of When starting a new business there are several things Barnstabl e. 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 COM ISSION R'S OFFICE MUST COMPLY WITH HOME OCCUPATION This individu I ha b n nfo deny�p�rt req irements that pertain RULES AND REGULATIONS. FAILURE TO in to this type of business.. COMPLY MAY RESULT IN FINES. Autho i Si nature** QM ENT ! G 2. BOARD OF H TH This individual has been informed f er equine ents that pertain to this type of business. MU `COMPLY WITH ALL. HAZARDOUS MATERIALS REGULATIONS Authorized Sign ture** 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: TOWN OF BARNSTABLE S+c'�.O ATION S 8 0AJQ(x,-re.N 111 QC/ SEWAGE # I's VILLAGE C &k-,ry```Q ASSESSOR'S MAP INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY `W: O Ge-A V-) c(D x � �Q LEACHING FACILITY:(type)�� (a �t'�f (size) L) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT IS 1c t SUED: l `)S G DATE COMPLIANCE.ISSUED: \7 . , , VARIANCE GRANTED: Yes No r- �� Clec✓�U� /A rtz, 96X Q4,j cltm(j%A Igo