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Home My WebLink About0076 THREAD NEEDLE LANE - Health (2) 76 THREADNEEDLE RD. CEN'ITERVII.LE Slll� l Y JAB llll • Nop2-153LOR HASTINGS,MN TOWN OF BARNSTABLE LOCATION -� Co 'gMt'«� ��.c cii-c_. �-�SEWAGE# 0, " j 0 VILLAGE G+o*-{fv� ASSESSOR'S MAP&PARCEL /, /n_-/ INSTALLER'S NAME&PHONE NO. C ft Sag ,:R94 Q d6y SEPTIC TANK CAPACITY gzT S� LEACHING FACILITY. (type) L-1'NC. NO.OF BEDROOMS OWNER -2-l n OAP PERMIT DATE: Vl L/I/7 COMPLIANCE DATE:_� A? 7 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 Aa raC4 ¢2 0 t .� TOWN OF B/ARNSTABLE LfX,A-I1GN 74 ��•h r one Ae- �cA SEWAGE # ILLAGE�- SN l',�3 Van 17 ��, ASSESSOR'S MAP & LOT &PHONE NO. _ �s� kC,eW a 9-, 7 b0 8 SEPTIC TANK CAPACITY i Oeo® CJ LEACHING FACILITY: (type) (size) "rod NO.OF BEDROOMS S �+ BUILDER OR OWNER MIA PERMIT DATE: ATE: loo Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 : . f .. � � ,. � � ��,, c 7 v 2� �` �.�` �o-�� 75 No. 1 ,®�" � G v Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS applitation for Misposal *pstrm Construction permit Application for a Permit to Construct( ) Repair') Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. V Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a( l�J (r,� ` Installer's e,Address,and Tel.Igo Designer's Name,Address,and Tel.No. n rnik O&W R 0-1y ocu 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) f f Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B �dotf ealth. / r Si ed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. l Date Issued FT_ No. ; V;✓ ✓/ 6 Fee 75 � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Disposal *pstem Conetrurtion Permit Application for a Permit to Construct( ) RepairV) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. (,-kCr•.r'C.G v r\C M Owner's Name,Address,and Tel.No. L Assessor's Map/Parcel �( o�I 61 Installer's ame,Address,and Tel.No. 2� Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures A Design Flow(min.required) gpd Design flow provided gpd Plan. Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) \ ( �( %evotZ,-, SuA k C— Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health.Sign Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued 01 ------•----- - ----- --- --- --- ---- -------------------- - ---- -- --- — --- THE COMMONWEALTH OF MASSACHUSETTS l BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( 1� Abandoned( )by at '7(�`(' �G c� n<G Cj�'� r.'� -has been constructed in accordance ` 1 with the provisions of Title 5 and the for Disposal System Constrvuction-Permit No 7 /,dated Installer �[�� (_,. Designer #bedrooms Approved design flow gpd The issuance of this permit}shall not be constnied as a guarantee that the system will c on*as designed. Date 1`) Inspector - r ------ ------- -- --------- -------- -- -- ------- - ---- -------- -- -- -- -- --------------- ----- -----. N 3�G/ Fee _75 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS \ MispoBal *pstem Construction hermit Permission is hereby granted to Construct( ) Repair""(L Upgrade( ) Abandon( ) System located at "��s„ 4AA(-mad A et6�-e. LCN. and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be com/vleted within three years of the date of this permit. - Date ��LJ / Approved by '`-�� -far -Ln-L Pt—C 4WX ilLb� PhaseCOIL/roo_c-�—Ifmavaw/� �J�ca_cP_h �L��o��0 Scott Frank 113 Old Yarmouth Road -- Hyannis, MA 02601 508-294-0069 • scottfrankl@hotmail.com To: ( bV Date w r\ RJ wv_ Description Amount r Ovv Cn-c' on 5 f( D w. `s L S- Co c,55 w S'� •\� ��G\�.1�: V3vk nod Total S U Next scheduled pump: H" Wage* �-f Please make checks payable to:Scott Frank 111ceaJ r 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 whin St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: b Ld Fill in please: APPLICANT'S YOUR NAME/S: F1 I;fie E 21 N D V BUSINESS YOUR HOME ADDRESS: 7( NaOLt= LN ,7�J TELEPHONE # Home Telephone Number .57)g LL14T6N 1�J,p�T"CA �R+�"`Aj.^ NAME OI CORPORATION. .'. NAME OF;NEW BUSINESS E OF BUSINESS IS'THIS A HOME OCCUFATION� ADDRESS OF BUSINESS -+ ��1~ P PARCEL NUMBER �� of C�,�! (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has peen M eye p the permit requirements that pertain to this type of business. MUST d;®MPLY WITH ALL (� (� �/ y I 14A ARDOUS MATERIALS REGULATIONS 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 Date: (p/ ,-2 W 0 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: Cn-P6 W lj)F Cl F--fiNl pj Cr BUSINESS LOCATION: 7(/ TNQEefl Nff I L l A• INVENTORY MAILING ADDRESS: 71p_ jdgEo-o NF%D� t N - CGNfE)eV I(I r/M TOTAL AMOUNT: TELEPHONE NUMBER: Cola b2 bay CONTACT PERSON: E(J7 aBEI F ?,wy EMERGENCY CONTACT TELEPHONE NUMBER: ';DR -,3(o-7- MSDS ON SITE? TYPE OF BUSINESS: CI M NCB- (O MPH"NY 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 IV R- 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) If h 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 Aj Car wash detergents Leather dyes VA 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 a �� Laundry soil & stain removers (including bleach) UeSIN(-r /Vi D 11 P, uc Spot removers &cleaning fluids (dry cleaners) T— Other cleaning solvents �! Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials U.S.POSTAGED>PITNEY 60WES Public Health Division BARN�ABLE. 200 Main Street639-M"S5: 4'p'ED MP+ Hyannis,MA 02601 dq g O, o �•�, 0 02 4VV �� !1 � i 0000336455 OCT. 03. 2016 7012 1010 0000 2848 1643 R� �J . R, QUf RRFC $J�d F/)Dr Demetry-and-Irene Zinov, Trustee 76 Thread Needle Lane C r Centerville, MA 02601 'li 1 7 1 E T 1: Ur 3- a✓a 1'0%.3 1 O I RETURN TO SENDER l 1 til r i_ $T fYl 3=f'S 9 I UNABLE TO FORWARD I VACKI: 93SZ20834S UNC i 8C: OZ601400200 *0322- 04990 `04-3r' iss,:ai.:i.��o.s;tRa'ti,.ils.,..:f:•:::ilti:�.. :;�•.a.v:;:i° °i• I ' it. 1 0260-2:1241 a 0 I Y ?ovs9 w zo ssszo9 ;dlaoaa wn;ea ollsawo0 ti00Z-iGenjg9=j :L l8£wao l Sd I I ([egel eolnaas w4.181suer0 II— -Eh9T 9h92 0000 O'COT 2`C0L aagwnlValo!Lro- Z I saA E3 (ead e/3�UGaAllatl Pa3ou;saa •y - - I •0.0.0❑ I1ew painsul❑ —� I eslpueyo 9IN aol;dleoea wn;ea❑ pe191si6aa❑ - --- - —— pri ssajdx3❑ Ilew Pe911180❑ I adAj eolniaS •£ I i i ZE9Z0 `dW 'aEfiA.Ia;uaO I I auel alpaaN peaayl9L saajsnjj'A0UIZ auail pue:-Aajaw@(j ON❑ :Molaq ssaappe tianllaP Jalua'S3A 11' o pesseippv9131VV -L I saA❑ LL wall wojl lueaaglp ssaippe AJOAilap sl •a •s;hied a ads 11;ucul ay;uo a0 'aoaldlpw ay;to moaq ay;o;Paao sly;pelly ❑ AiaA119010 a;e0 ,0 (every pe;uud)Aq 139Alaoaa -9 •nog(o;paao ay;uan;aa uao aM;ay;os aassaappy❑ x as.lanW ay;uo ssa.Ippa pua ewau anoA;uud ❑ I ;ua6y❑ •paalsap sl fJ9Allaa Pa;Ole;saa 11 V wall aanteu6lS y ejeldwoo osly'E pua'Z'I,swell a;ald=6 ❑ s, z f��it�In1 °�� py� �. 'h.. W Pa..0 CUrtt�FL"tl,lLlAil:C'/a. 0- a' a_. � ... 1 f� \'1, � ii a.�'.�- \ I �\ I I �\ "^i—. :�'�F \�\ Sri.' �\ l iR \ t - `.�' 1 i t I 1 f ,� -� LP w CON IONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE AF ENVIRONMENTAL AFFAIRS, DEPARTMENT OF ENVIRONMENTAL PROTECTU 1,; TITLED 5 OFFICIAL INSPECTION FORM-NOT FOR VOLLNTARY ASSESSMI:N'T!�� .SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM FAR'r A CERTIFICATION Property Address:__7 4 �3 ea Ile Iam' t Owner's Name: i ' Owner's Address: NM g 030 Date of Inspection: � 1.1 NJ CO V lt IPA Marne of lnspactor: plea a print) �f e 4 at I Kel lie t# Company Name: rg P ':Vf✓iCg an.mG^*71 .1 ove cito'.5 Mailing Address: ei t3 6= Telephone Number: CERTIFICATION S,TATEI F-NT I certify that I have personally inspev-.ed the sewage disposal system at this address and that the informati,wi eported Wow is trine,accurate an4 complete is of the time of the inspection.The inspection was performed bored of my training and experience in the proper function and maiatem[ce of ors site sewage disposal systems.I am a 1;EP approved system inspector pursuant to Section 15.300 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority galls Inspector's Si<gnatt ire: � Date: The system inspector sti al:,submit a copy of this inspection report to the Approving Authority(Board of l in 1th or DEP)within 30 days of compieting this inspection.If the sy:ttem is a shared system or has a design flow of 0,a?0 gpd or greater,the inspector and the system owner shall submit the'report to the appropriate regional w1iic:e )f the DEP. The original shot,Id be sent to file system owner and copies sent to the buyer, if applicable, and tie ap troving authority, NCAt- j4 O W(' Notes and :orrsuents ' 5C o S. ""This report only describes conditions at the time of inspection and under the conditions of use-a". that time.This inspection c'lor:s not address how the system will perform in the future under the samt or c,efferent conditions of use. Title 5 Inspection Form 6/15/2000 page 1 k Page 2 of 1 1 OFFICU1, INSPUMON FORM—NOT FOR VULUIN rARY ASSES S1ad:.;:.N17S SUB-31URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FiMU!,( PART A CERTMC,kTION(contmued) Property Addrw_ 76 r ri Pit e,Al j►...�t e.� r Owner: /S s6A Date of le peetto-m I t cw Inspa:tion Summimy: Check A,B,C,D or E/ caip6els aH of 9■sttiv n . A. System Passst: —L I have not llaund any inforasation which indicants that any of the failure criteria described in:.I OM 13.303 or in 310 ClV(R 15,304 exist, Any&ihn criteria not evaluated are indicated below. Comments: t B. System Cond ktlimally hassles: One or mot :;ystert components as described in the"Conditional Pass"section need to be repl.:ed or repaired.The syste:a,.upon completion of the replacement or repair,as approved by the Board o Me:a.P:.,will pw;s. Answer yes,no or not determined(Y.N,ND)in the _for the following stateme f"not deterrrihi rd'pletxe explain. The septic t;mk is metal and over 20 years old*or the septic whether metal or not) is struc-uraliy unsound,exhibits i ubstantial infiltration or exfdt 2don or tank is imminent. System will inu bu pecdatn Vthe existing tw*is rep lasted with a complying septic tank as appro by the Hoard of Health. 'A metal septic tar k will pass inspection if it is stnretut ally d,not leaking and if a Certificaae of C i enpiiwitc indicating that the arik is less than 20 years old is avail ND explain: i Observation e f sewage backup or out or hiO static water level in the distribution box dt;., to.tedont.or .. obstructed pipes),or due to a broken,sett or m r*vn d�n�on box.'System will pass tupeedcm.i1 (with approval of Hoard of Heahh): . . P*Ks)see sapitaed _ obstu:don is re amed distribution box is lesvaled or replued ND explain: The system.A4quired pumping more th m.4 tis mi a.yew dut to broken or obso acted pipe(s)."i1t systera will pass inspection' with approval of the Board ofHealft broken pipe(s)are r+eplued obstruction is removed ND explain: 2 N Page 3 of 11 OF11CLAL DPISPECTICIN FORM•NOT FOR VOLUNTARY ASSESSMENTS SLBSURFA►CE SJENVAGE DISPOSAL,SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Owner. r' Date of ins on:_ ULL t p e C. Further Evaluatioc is:Required by the Board of Healil: Conditions exist which require huther evalustioA by tl1e Board of Health in order to determin thr,; strm is failing to protect publi r,health,safety or the environment. 1. System will pass u:alas Board of Health determines in accordance with 310 15303(1;i(b)t 4t tht system is not futictioniag is s,manner which will protect public health,safe nd the enviroaatizt: Cesspool or privy is within SO feet of a surface wirer Cesspool or privy is within SO feet of a bordering vegetated wetlsn r a salt rttarsh 2. System will fail unless the Board of Health(and Publi star Supplier,if any) determines tbal !ihe system is functionin;;in a manner that protects the pub health,safety and environment, The system has a septic tank aad soil absorpti system(SAS)and the SAS is within 100 fret ea a surface water,supply or tributary to a surface w sn.pply. __. The system has a septic tank and SAS d the SAS is within a Zone 1 of a public water supply. The system hats a septic atrtk and S and the SAS is within 50 feet of a private water supF iy yr lt. _ Ilse system has a septic gRak d SAS and the SAS is less than 1t)fl feat but 58 feet or more fraiu a private water supply well".hi od used to determbie distance °°TMs system ps`ssZn sll water analysis,perftrtned at a DEP certified laboratory,for eoliftni bacteria and volatilxapounds indicates that the well is$ee from pollution from that 1wili:y and the presence of s miitgen,and nitrate nitrogeat is equal to or less than S ppm,provided filar rn other failure criteria at� ,copy of the analysis trust be attached to this form. 3. Oth : 3 Page 4 of 11 OFFICIAL. INSPECMON FORM—NOT FOR VC)LXTi jM ASSESlgA41 il.mrs SUBIAMFACE SEWAGE (DISPOSAL SYSTEM lEIe�PEC'riO1��:�II1r I: Pe4RT A CERTIFICATION(continued) Property Address;_7 9`71 Oww r. a V1 Date of Imp l:, D. System Falls -a Criteria al►plkable to all sytttemtn. You ll m indicate')vs"or"no"to each of the fallowing ft jiLinspeetions: Yes N Backup of sewage into facility or System component due to overloaded or clogged SAS or ; ospocl. Q Discbarjpp or pond*j of ePttuent to the surface of the ground or surface waters dram to,tn w !rloadeni i:,r clogged SAS or cesspool ;00 Static liquid level in the disc ftdon box stave outlet invert due to an overloaded or 60111;14 SAS or cesspool Liquid 4epth in cesgmol is less than 6"below invert or available volume is less than'",da;r lov, Requir:,d pumping more than 4 times is the last year N=due to clogged or obsouetead pil,i(s).Number of titws Ip __ /tom Any pc:rdon of the SAS,cesspool or privy it below high ground water elevation. Any pc rtion of cesspool or privy is within 100 feet of a surface water supply or tributary to ,i surface ,L,6water:iupply, Any pc resort of a cesstpool or privy is within a Zone I of a public well. Any pc rtion of a cesstpool or privy is wittin 50 feet of a private water supply well. Any pc rtion of a cessppool or privy is less than 100 feet but greater than 50 feet from a p,rivs,-e water supply well with no acceptable water quality analysis, (This system passes if the well Nrs i ;:r analyysis, perfor med at a DEP certified laboratory,for coliform bacteria and volatile organic cv tnpouads indlea m;that the well is free from pollution from that fact tg and the presence Of noel nonia nitrogen and oltraft oitroeen is egnal to or ku them S ppts.prov W that so other ft lameertnria are triggered.A copy of the analysis must be attached to this form.) (YesNO)This system jAlk.I have determined that one or more of the above failure criteria ecxi t as desc ritiercl in 3 l0 CNIR 1 S.303,dwefam tlae systtem fail&Mw system*tuner si aUW extctaj: tits'&U f of Health to determine what will be necessary to c a the bib E. Large Systems: To be considered:t large system the syste ust pmrre a tae3lity with a design fkw,of 10,000 gpd i o 15,O)o gild. You must indicate;tither"yes"or"no" each of tree fogfilr atg: ('The following criteria apply to 1 terns in additioa to the etisz&above) yes no the system is wi 400 feet of a:tstdaoc:fratiriag wader supply the system 1 ithin 200 feet of a`tzibtasey to it smfltae drinking water supply the syI rn is located in a nitrogen sensitive area Interim Wellhead Protection Area—IVIPA'i or a maplx!1 Zo of a public water supply well If you l e answetud"yes"to any question in Section E.the system is considered a significant threat,< answered "y " :n Section D ibnve the large system has failed.The owner or operator of any large system comsic :red a nificant threat under Section E>or failed under Sectio;x D shall upgrade the system in accordance wii:; 310 Cfv[.R 15.304.The systern owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICLAL ViSPECTION FORM—NOT FOR VOLUN I ARY ASSESSMEIN11, SURSUR.FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI PART B MCKLIST Property Address:2j�77r-VkS,%4%eAje kA of owner. 01f r-Ia 111 vt Date of 1nspsction: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: .ru---s. Yes No Pumping infannation was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks M y Has the sysn:m,received aormal flows in the previous two week period? �( Have large volumes of water been introduced to,he system recently or as part of this inspection Were as buil plans of the system obtained and acamined?(If they were not available note as Ni,� ) Was the faci'iry or dwelling inspected for signs e f sewage back up? Was the site inspected for signs of break out? ..� Were all syscetn components,excluding the SAS,located on site? A' _ Were the septi tank manlaoles uncovered,opened,and the interior of the tank inspected for the i:�mditian of the baffles or tees,m su:rial of construction,dimensions,depth of liquid,depth of sludge and depth of s:cc:-n? Was the fac:lity owner(af:d occupant$ifdifferert from owner)provided with information on the-proper maintenance of subsurf io:sewage disposal systems ' The size and location of the Sall Absorption Syslees(SAS)on the site has been determined bas4: ;om Y es no Existing inf irrnation.For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part Cis at issue approximat,on o I'disrurce is unacceptable)(310 C MR 15.302(3)(b)) S Page+6 of 11 OMCLIa,INSPECTON FORM-140TYM VOLUNTARY A RCtt!N!I1::N*r& SUBSURFACE SEWAGE DISMSAL SVEMEM INSPECTION F1:YR.'''-1 PART C SYSU MI INFORMATION Q Prpo ey►Addren+•, 74 1,r?kd A-eed *-4 Owner: Date of a: now corfDtnoNs RESIDENTIAL Numbear of bedm c lsu+(design):, Number of bedrooms(actual): DESIGN flow baaad on 310 CNOt 13103(tor example;: 110 gpd x#of bedrooms): Number of current reside:s) Does residem ba,.v a garbage jrWer(yes or no): � Is laundry on a separate sewage system(yes or no): P[if yes separate impection required] Laundry system inapected or no):1Q Sexteonal use:(yes or no) Water meter readin.ga,if availabie(hat 2 ye an usage Ulpd)): M G Sump pump(Yes o-no): 1D Last date of oecup teary: 00 �� COMMERCIAL VIDUSTItU►L Type of eambiishrt+erit: Desip How(band on 310 CM 15.203): •_gpd Basis of design flaw(seats/pe:rsesnalsgiR,ac Grease trap pal:(:m or no): _ Industrial waste he ld ing tank pnnen or no): / Non-sanitary waste,discharged t e Title S system(yes or no): Water teeter readu.gs,,if ava' e: Lase date of occup m�:y/us OTHER(describe GENERAL INVORKATION Pumplag Records t, Source,,of infotmatioit: e Was rmtem pumped as part of the inspection(yea or III)): If yes,volume pumped:�,�gallons--Now was quantity pumped determined? Reason for pumpit g: TYPE OF SYSTEM Septic tank,di:ttribution box,soil absorpdn ttpraecs _..Single eeaapoul Overflow ce:g;3031 Privy Shared system.(yes or no)(if yes,attach previous htepection records,if any) Ianovative/Ali:ernative technology.Attaelia copy aitihe 1, operation and makae"nCe cantra1:t(to be,, obtained tom system owner) _Tight tank ,,,-,Attach a espy of the DEP approvd f1 _Other(describe)- Approximate age of all cgq�mponents,date installed(if luiownl and sourc of information: T— Were sewage odors detected wheen arriving at the site()es or.no): NU 6 j Page 9 of I l i OFFICIAL. IMPEC rION FORM—NOT FOR VOLUNTARY ASSESSN[E.:i'CS SUBS AWACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION(continued) Property Address: Owner:�JqL Date of luspeetfon: 3j, WhWb BUILDING SEWER.(locate on rite plan) i a Depth below grade:.+kl'a � Materials of conso u+:tion:_cast iron _k40 PVC_other(explain): Distance from private eater supply well or suction line: Comments(on coed;t.on of joints, ventin&evidence of leakage,etc.): SEPTI(:TANK:V_;locate on site plan) D fly below e:JI . . Material of construccio.n:,concrete metal__,_fiber,`iass polyethylene _other(explain)T,__ If tank is metal list a;Ia Is ae;e confirmed by a Certificate of Compliance(yes or no):_(attach a ;apy of certificate) Dimensions: 1A4'rg► G Sludge depth: x�2-- Distance:from top of c I j ge to bottom of outlet tee or baffle: Scum thickness: Distance From top of scum to top(if outlet tee or battle: Distance from bottor.a of scum to lwttom of outlet tee or I)altte: j How were dimensior� determined. 1 Comments(an pumpi.ai;recommendations,inlet and outli;t tee or baffle condition,structural integrity,l.ic ::id levies as related to ou;jct avert,evidence.of.leakage,etc). ` GREASE TRAP:_._(locate on site plan) Depth below grade- Material Material of construetion:�coacr:te __polyethylene__,_other Lu (explain}; _ Dimensions: —� Scum thickness: 1 Distance from to of:ictun to top o,l et tee or ball&_ Distance from bottom of scum t MOM of outlet tee or bail]Me: / Date of last pumping:_ -- Comments(on pumpi sg ommendations, inlet and outlet tee or baffe condition,structural integrity, laq►:id levees as related to outlet invpe evidence of leakage,etc,): i Fame8ofil OFFICIAL INSPECTION FORM-NOTIOR VOLUNTARY ASSES!ilia,NTS SIU13SURFACE SEWAGE DDIPOSAL SYSTEM INSPECTION]B'p;1101 PART C SYSTEM INFORMATION(c—pi- d) Property Add re e_eo�a L"*�4 . Owner:�� tso► Date of Impal6m:---�� TIGHT or HOLDING TA X:_(ti ak must be pumped di®pet; xkpizi oft vice pn) Depth below gre de: Materiel of corisenxtion:_coacrete matal tl glass____.polyethylenc odaerta►xl ls in .100 Dirnemions: Cspacity:.�,. Dessip Flow: day Alarm present,,j,m or no): Alarm level: m workias order(yet or no)•. Date of last p7wn'pirts: Comments(coitditio alarm and Boat switeltes,etc.): DISTRIBUTION BOX: (if present must be ap medXtocate on site plan) Depth of liquid level above cutlet invert: Comments(note if box is level and distribution to 01tlets equal,any evidence of solids carryover, airy evidence of leakage into or out of�x�et+c,); PUMP CHAMRKR• (locs on site plats) Pumps in worldos order ems): Alarms in work;ng or or no): Comments(M:pTdition of pump chamber,ooeditioer of pts�af a a sdappumeneaams,etc.): a Page 9 of i 1 OFFICLAL VISPECTION FORM-NOT FOR VOLUNTARY ASSESSMXNI'C 9 SUBSUPJF'ACE SEWAGE DISPOSE L SYSTEM INSPECTION FORM: PART C. SYSTEM INFORMATION(cmunued) Property Address:,1�' � ew42P- �k-6--AG �-.�`�. - Owner: 0 Date of Inspection:___ 1A 1 -12�k� SOIL AB'SORMON SYSTEM(SAS): le (locate on site plan,excavation not required) If SAS nct located exhLsin why:- T , leaching.pits,nurrtwe leaching chambers,number. leaching galleries,,number._ leaching trenchei,number,length: leaching fields,nLanloa, dimet>sions: overflow cesspo,r,number. inn ovative/altern.aCve system Type/name of technology: _ Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of veji:tation, etc.): 30 -- A o 'tTL. ibw\ 1au.a v� ti s 2�o lets-�►c `� 'B� ) ►'�s a,re, ><� �e��,si-. 5Q CESSPOOLS: cesspool must be pumpadhs part-o(utspecaon)(loeate on site plan) �s` Number and configure t ion: Depth-top of liquid to inlet invert: Depth of solids layer, Depth of scum layer:___ Dimensions of cesspt ol: Materials of construction: Indication of groundwrtl7 inflow(yes or no): Comments(note c ition of soil,signs of hydraulic failum,level of ponding, condition of vegetation;,etc.l: PRNY: (locate,:,n site plan Materials of constructijn: Dimensions: Depth of solids: Comments(note c on of soil,signs of hydraulic failure:,level of ponding, condition of vegetation,etc.; 9 Pape to of i l OFFICIAL INSPECTION FORM-NOT IM VOLUNTARY-ASSE S!i 1 U.N I'S S U13SURFACE SEWAGE DI:;POSAL SYSTEM WSPEMON 1?"6 4thl PART-C SYSTEM INFORMATWN' ued) lhn* ty Add revs: 7 .� Jt Owner: SKETCH OF SIEWAGE DISPOSAL SYSTEM Provide a skewh of the sews ge disposal system including ties to at lean two permanent retbrenae I i aidmarkc or be=hmLkL Locate all wells within loo feet.Locate wham public water supply enters the buadira;. N-D kc�praA ' S t V i IC'r 5��k, 10 Page 11 of It OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSI'NU ITS SUBSURFACE ,SEWAGE DISPOSAL SYSTEM INSPECTION FORAM PART C SYSTEM INFOINATION(ca=ued) Prolwrly Address: Owner: , Date of- a: SITE EXAM Slop Surface aster Cheek cellar Shallow wells Estizmed depth to paund water.li-I feet Please indicate(cho:k)all methods used to determine tht:high ground water elevation: Obtained from system design plans on reed.If checked,date of design plan reviewed: Observed site ;a mtdng propeaty>observation hole within 130 feet of SAS) Clucked with Imal Board of Health-explain: Checked with local excavators,installers.(attach documentation) X Accessed USCS database-explain: tJG G5 tti �mQa __„ You roust describe loins+you established the high ground water elevation: t�t-7PJA ,!;i_0,�� td tt POO ed kw~: ROOM GKOUNWWATION LIVIL COW TATION Site Lom*n:. -71 bA.1. FretMo. fir: mwr. I - C 4 CN Now: STIFF, I AN w WSW foole toform I . .... ................................................................ last, a UO"wow Wgvv it"am organ VANJ mw mww to NW ftimfolow: P! --Ww mot... ................................................ $Tap, 1v"w""Cw"em wow Amo"ONW6 low' do"I to I V.i I fWA dlpt%to *vw level tot Owlem ram! ..... UgalydAl 14 Wdr-lov*Ad%NWNM qw wow 160441 Oro U4.am""loth 1w Ind"VON WTOP 8). wow 8161 um Wof 41610*ft 01RIP-16VO MOAN"" ..................................................... ............ pit 6 �Mvat"Ji oil,on am?- edwelm"(w"v 44 ,. m old doom go Wm fro"Ow ............ ......................... jowlat on*ISM 11 ................................................ OfCATION SEWAGE PERMIT NO. NI-L LAG E I N S T A LLER'S NAME A ADDRESS GUILDER OR OWNER- DATE PERMIT ISSUED Juive, DAT E COMP"LIANCE USSUED � 056 4 rcA di THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..................... .. .............OF........................................--------------.._.... Appliraftan for Diapati al Work Tnnitrurttun anfit Application is hereby made for a Permit to Construct or Repair an Individual al Sewage Disposal System at .... 425.._�. .... ................... ..... ... .-•......... Location-Add e � o Lot No. n .. w Address __ Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------- ------------...-------------------••••-•......._.._..-•-------•----•-••-•••--.....-•-....--•••••......._......-•-•-•..... W Design Flow.............................L5 . •_g__ s per person per day. Total daily flow.......ZSC....................gallons. WSeptic Tank—Liquid capacity -..gallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (k) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1....:...........minutes per inch Depth of Test Pit.................... Depth to ground water.-_._-__________---____. rzq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M ..--••••••--------------•------••-•-----••-•----......•••-•---••....-•--................•---•.•••............................................................ 0 Description of Soil........................................................................................................................................................................ W -----------------------------------------------•----------------------------------•------------------------------------------------------------------------•-------------------------- ---------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------------------•-------------------------------------•-•--•-••-......---••-••••-•-------------••--•--•-•-----••••--•-•--•--•-•-••-•-•••----•--•-•---•••-•••-••-•-•--••--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sa ' ar — u signed further agrees not to place the system in ' _' operation until a Certificate of Compliance s be u b b rd of health. tiff. Signe ----------------------•--------------------•- ................................ Date Application Approved By.._.__.._......... :. ,t-• �- - . .... _....._.._. --------------------------------- p Date Application Disapproved for the following reasons---------------•-----------------------------------------------------------------•---------------------......•••- ... -- ---------------------------------------••----......•••••---•- Date PermitNo......................................................... Issued................••-----------------•--•......------•--•- Date No......Q. ._�. a ~ FEB......J.. ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... ........--.....OF.........................-� .......... Appliration for %gpoiittlWorks,-Tnnxitrurtinn thrutit Application is hereby made for a Permit to Construct (i' ) or Repair ( ) an Individual Sewage Disposal System at . ._ .. -- ------•---•------------------------------•-- ---------•-•......•-----............------ Location-Addr s or Lot No. •.. UAe, ....•.............. ..........................................•---------••-......------......•..................•..... ne •"" Address Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..............:.............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons_...___.............._.___. Showers ( ) — Cafeteria ( ) Otherfixtures`'--------------- •-------•-----•---•--•---------••-•--•--•---•-••------------•-----------••---•-•-•-- •-- WDesign Flow............................................gallons per person per day. Total daily flow------ -�> ...................gallons. WSeptic Tank—Liquid capacity............gallons Length...:%.......... Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.................... Diameter.................... Depth below inlet.................... Total 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...........------------- 44 Test Pit No. 2................minutes_per inch Depth of Test Pit.................... Depth to ground water........................ t� ......----•----------•----••----------------•-•---••---.....------••-------................................................................................. 0 Description of Soil............................ -------------------------------------------------------- ----------------------------•-•---------------------•-----•••---........-•--•• U ---------------•-----•••--•-----•--•------...__...------......-•--......------------••-•-•----------------•---••-•---•----------•----•---------------•--•------•---•--•--•---------...........-------- W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..................•----••-•---.........------.....-•-----------•-•--•-•----•-••-•-•---...----•--------------••--•-•-------------•---•------•-•--••---•--•--•-..........---------•---••-••-------------•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLij 5 of the State San' ary e u r igned further agrees not to place the system in operation until a Certificate of Compliance h s bee, ue o rd off health. Signed__ ............................................ --- ---_... ... ID e X Application Approved By----------.. < , _..... . 40 Date Application Disapproved for the following reasons:--••----------•---•---•------------•--.......---•----------------------------------•------...--•---------..... ........--•---•.................•---•---...--•---------•-•--------•--•-•-•-----..._...-----•-•----------.-------------------•---••••-----••--------•----------•-•-------••-_--••----------••-------•.... Date PermitNo......................................................... Issued-...................................................... Date . . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifiratr of �unt�rli�nrr THIS IS. ERTI.F , Th Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---------------------- _:._ ------.._.........-•------•-------••------......---._....---•----------•------•-•-•----------•----•---...-•----•-•-•----......----- 1 . at ....................4 WI ---_•ir.�'�_..Inst 'i' has been iustalled in accordance with the provisions of TIT r ` of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._ ..-.��.�................ dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACjPRY. DATE.............................•..................... . ..(.. Y-•---. Inspector........------------ I iL....---......................-- j- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ................................................. .. � . OF.. No..................... FEE.--.- -.. Raposa1 Vorkii Tonotrudion VarAit Permission is h eby granted.....__ .. } ....._ � .. - ------ to Construct (JVTor Repair ( ) an Indiv al ewage Di posal , at No Street as shown on the application for Disposal Works Construction Permit No.............Oo. ,d .....__ Dated.......................................... Heal thh DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ,.,, ...yr..... -,..._,.....,...>..r,. ,.1s=._.w..-.....,..r,•.•..W......,...,,..�,.,�:...:.�.._.....�.::.,.......,:......:.,.,. ....».m.....m..:,.-..A„o,,..,,» -,.... -,»w=."�».,.,»»,..« .. __ - :.ram.*.� ,...,.,. ,,....> »a..., vim. ....«� .,,,..,,..�.......,........,.,...,.........:�........,....�...,.+..r.�. 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