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HomeMy WebLinkAbout0849 STRAWBERRY HILL ROAD - Health 849 STRAWBERRY HILL RD., CENTER. A=230.173 A a UPC 12534 No.2_153 OR ' HASTINGS,MN 1 i 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: LA- Fill i please: APPLICANT'S YOUR NAME/S: M ak -` BUSINESS YOUR HOME ADDRESS: ' lq q' 947rea,,i 1xrhg 14111 r v * •M d�L3� � Sv£s-36y�3�7 ` TELEPHONE #� Home Telephone Number SnR—:5hu —3&7.3 NAME.OF CORPORATION: �Ns '.' NAME-OF NEW BUSINESS ti-A VFLA><i L4And S (-,got, C TYPE OF BUSINESS L 4 �oN ISTHIS A HDME,OCCUPATION? YES NO 7 2 ADDRESS OF BUSINESS r R ��I �. C A MAP/PARCEL NUMBE � I LJ (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 CO fal SSI ER'S OFFIC MUST COMPLY WITH HOME OCCUPATION This individ e n m f req�mentthat pertain to this type of businessRULES AND REGULATIONS. FAILURE TO Au hor' ign re** COMPLY MAY RESULT IN FINES. OMMENT d In etr 1 2. BOARD OF LTH This individual has been informed of the perm' r quirem t at o this type of business. MUSS COTVIPLY ALL HAZARDOUS MATERIALSS R REEGULATIONS Authorized Signature* 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 Dater TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: ,•� „ ,� e ,� BUSINESS LOCATION: Fy�Iy Sk raw Lor,�w 4i l I Ccnv�wl� a ev'INVENTORY MAILING ADDRESS: PD f309 ') wl �49-y nowl TOTAL AMOUNT: TELEPHONE NUMBER: — CONTACT PERSON: t-16AACjQA1K EMERGENCY CONTACT TELEPHONE NUMBER: y - SsSs7•4 MSDS ON SITE? TYPE OF BUSINESS: L/A INFORMATION / RECOMMENDATIO : 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) � a 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 (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Signature Staff's Initials Z 203 499 131 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. �) Do not use for International Mail See reverse Sent to �� umoSJ r'.Z1 A0a° P Office State,&Z Code �f4 /yid OZ 6sZ Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to Whom&Date Delivered Q Return Receipt Slowing to Whom, Q Date,&Addressee's Address QTOTAL Postage&Fees $ 477 th Postmark or Date 0 uL rn a I Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of'the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the � return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article Q RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the 0 addressee,endorse RESTRICTED DELIVERY on the front of the article. 0 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti 6. Save this receipt and present it if you make an inquiry, 102595-97-8-0145 a i Town of Barnstable Department of Health, Safety, and Environmental Services � ntSTAB & 9 659. Public Health Division P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Paul White July 9, 1998 849 Strawberry Hill Rd. Centerville,MA 02632 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 849 Strawberry Hill Rd., Centerville was inspected on June 17, 1998, by John Graci, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CUR 15.00) due to the following: • Soil absorption system (SAS) is in hydraulic failure. The liquid level of the wastewater has been over the invert pipe. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis)that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (30)thirty days of receipt of this notice. You are also directed to bring the septic system into compliance within sixty (60) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. I. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF T BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health q\health\dbfiles\titles i.doc cc: T. Geiler I Grad Tom, Town of Barnstable MMM�Ae Department of Health, Safety, and Environmental Services >� Public Health Division i639• 1� & 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A McKean,RS,CHO FAX: 508-790-6304 Director of Public Health TO: P L z DATE: J� ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. . The septic system owned by you located at 1(`1' ' A-11 was inspected on —,_ �� I by �S t��, r-�,,' , a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00 due to the following: o c You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 withh aT=^T=amen days of receipt of this notice. w,%, �Vp 64�'-A Off% You are also directed to bring the septic system into compliance within tlirt0) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health yveWm�riawuui.dDc 'A � C/ Commonwealth of Massachusetts Executive Office of Environmental Affairs IN Dept. of Environmental Protection • One winter Street, D.E.P. "Titlee V Septic Boston Ma. 02108 Jitlepti c Inspector P.O. Box2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ORT A CERTIFICATION Property Address: 849 Strawberry Hill Rd.Centerville Map 230 Lot 173 Address of Owner: Date of Inspection: 6117/98 (If different) `" 110*' + Name of Inspector: John Graci Paul White h��Tegq I998 I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) yDFNSTgB ` Company Name,Address and Telephone Number: a 6 r CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true; accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes This Inspection Is based on criteria donned In Title V _ Conditionally Passes code 310 CMR 16.303.My findings are of how the system is performing at the time of the inspection.My inspection does Needs rth rEvaluationBytheLocalApprovingAuthority not Imply any warranty or guarantee of the longevity of the x Fefis septic system and any of Its components useful lire. Inspector's Signature: #ubmit Date: 6118l9s The System Inspector shall 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: 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 — CoThpliance(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 04727197) One Winter Street . Boston,Massachusetts 021108 a FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 949 strawberry Hill Rd.Centerville Map 230 Lot 173 Owner: Paul White Date of Inspection:6117fg8 — Sewage 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 of a private water supply well. — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the 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: x 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 _ _X_ Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. x_ Discharge or ponding of effluent to the surface of the ground or surface waters due to on oveilouded-ol clogged cesspool. x_ — SAS is in hydraulic failure. (revised 04127S7) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 849 Strawberry Hill Rd.Centerville Map 230 Lot 173 Owner: Paul White Date of Inspection:6117198 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 coliforin 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. (revised 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 849 strawberry Hill Rd.Centerville Map 230 Lot 173 Owner: Paul White Date of Inspection:6117199 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. _X— — 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)] - (revised 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 849 Strawberry Hill Rd.Centerville Map 230 Lot 173 Owner: Paul White Date of Inspection:6117198 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 0 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: May11998 COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:U 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: rda Last date of occupancy: rda OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: rda System pumped as part of inspection:(yes or no)No If yes,volume pumped:0 gallons Reason for pumping: rda 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: 1986 Sewage odors detected when arriving at the site: (yes or no) No (reyleed 04127197) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 849 Strawberry Hill Rd.Centerville Map 230 Lot 173 Owner: Paul White Date of Inspection:6117I98 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age Ala . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L8'6"h5'T"W4'10' Sludge depth:9" Distance from top of sludge to bottom of outlet tee or baffle: 19" Scum thickness:1' 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: 1e" 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.System needs to be pumped now and then malntalned every 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:rda 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: 2'6" Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line?own Diameter: nla_ Qe1mments: (conditions of joints,venting,evidence of leakage, etc.) (revlsed 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 949 Strawberry Hill Rd.Centerville Map 230 Lot 173 Owner: Paul White Date of Inspection:6117198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nra Capacity: rJa gallons Design flow: rva gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) No DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: Liquid level has been over pipe Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) The distribution Is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)—Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) n/a (revised 04117)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 849 Strawberry Hill Rd.Centerville Map 230 Lot 173 Owner: Paul White Date of Inspection:6117199 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: 1000 gallon leach pit leaching chambers,number:rda leaching galleries,number: rda leaching trenches, number,length: rda leaching fields, number, dimensions:rda overflow cesspool, number:n1a Alternate system: n1a Name of Technology._rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leach pit le past the effective depth of leaching,system Is In hydrualic fallure,Ilquld level has been over pipes. CESSPOOLS: (locate on site plan) Number and configuration: rtla Depth-top of liquid to inlet invert: We Depth of solids layer: rda Depth of scum layer: rda Dimensions of cesspool: rda Materials of construction: n1a Indication of groundwater: We inflow(cesspool must be pumped as part of inspection) ` nfa Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n1a PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: n1a Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) We trevleed 04127197) L i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 849 Strawberry Hill Rd.Centerville Map 230 Lot 173 Paul White 5117198 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) =' 3� 1� 3v� p 4 a7 M ',c 6S9q 6C 37 g� (revised04127197) Page 9 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) $49 Strawberry Hill Rd.Centerville Map 230 Lot 173 Paul White 6117199 Depth of groundwater 121 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 TOWN OF;BARNSTABLE S I -rJ� SEWAGE # j� � SE AG LOCATION ��' -1 � � � �r VILLAG /ASSESSOR'S MAP & LOT 17 S INSTALLER'S NAME&PHONE NO. I�f�,�/ Jo7TL � SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER_ -� PERMIT DATE:. 49 . COMPLI .NCE DATE: Separation Distance Between the: " ' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C /Ozo Ltd Grp r ���o L�AC-14 Movc14 No. A Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: +/ ' Yes 'PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for ]Digpo!6a1 *poem Construction permit Application for a Permit to Construct( )Repair(1*/)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No.,f q G C�1. � Owner's Name,Address and Tel.No. Assessor's Map/Parcel 3 ® /7 Z Installer's Name,Address,and Tel.No. /�Qc� f� ( Designer's Name,Address and Tel.No. —Y Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow I/® gallons per day. Calculated daily flow `Z3,0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1060 / Type of S.A.S. _ , t 7C -/ 1 ce"- Ttog� Description of Soil 6 -1`L dA1'? 1T'tJl ee-1,451 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Titl fatheoynm Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b t 's Signed Date Application Approved by _ + Date 7-2-9 Application Disapproved for the following reasons Permit No. Date Issued 7 1 80 Y TOWN OF BARNSTABLE LOCATION T` I I� L�.�� �.L.� SEWAGE # 1;i�� VILLAGE—���Z � ASSESSOR'S MAP & LOT l INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY '-/OOL LEACHING FACILITY: (type) NO. OF BEDROOMS BUILDER OR OWNER 7 f�V NCE PERMITDATE: (_COMPLIA DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by No. / y` / Z Fee .� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Migogal *pgtem Congtruction permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. ,,f q s'FR,Q/ Owner's Name,Address and Tel.No. OA Assessor's Map/Parcel7i-3 O /7 3 C �/t-lK f—J Installer's Name,Address,and Tel.No.� �/9t/UT't� Designer's Name,Address and Tel.No. a0 7REETolO C/R /n,4)g6To,6 Type of Building: Dwelling No.of Bedrooms�_ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1127 gallons per day. Calculated daily flow -.7310 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank A000 Type of S.A.S. T&A611 Description of Soil Q^'��L191�/�? 1,j0-.? cl-2,45J Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title f the onm Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b Bo o e Signed Date Application Approved by _ Date 7_�JP Application Disapproved for the following reasons Permit No. 77 Date Issued 7 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERT Y, that the On-site Sewage Disposal System Constructed( ) Repaired Upgraded( ) Abandoned( )byR rA�i Ay�ri� at I—ru'j go, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ZE 97 9 dated 7 Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date C) (W Inspector t / V ---------- =.__ — __ No. '-/� -- ---off Fee .�" , ,-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS M005a[ *p! tem Congtruction Vermit Permission is hereby granted to Construct( )Repair L,)eCJpgrade )Aba don( ) System located at9 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this perrilit. Date: Approved by C �~ 4 i 10/9197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) `,Q�I, 1f1� ��� 4 ►hereby certify that the application for disposal works_ construction permit signed by me dated concerning the property located at meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system E • There is no increase in flow and/or change in use,proposed _w • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will W be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) © B)Observed Groundwater Table Elevation(according to Health Division well map)3o SIGNED DATE: LICENSED SEPTIC SYS INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert ! i C r f 1 lajO , GAt&jxtThl4k 17, o