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HomeMy WebLinkAbout0204 WHITE OAK TRAIL - Health 204 WHITE OAK TRAIL, CENTERVIL11 A=192-201 1 No. 42101/3 ORA ESSELTE 10% A O O O tip BORTOLOTTI CONSTRUCTION,INC. �, J U N 2 6 1997 765 WAKEBY ROAD,MARSTONS MILLS, MA 02 �i 508-771-9399 508-428-8926 FAX: 508-428-9399 r�wNFAITNI STABLE S SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTIO PART A S y CERTIFICATION Property Address: Q 1. Date of Inspection: 7 Inspector's Nqun er's Name and Address: T s CERTIFICATION STATEMENT* I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes eeds Further Eval 'on By the cal Aproving Autltority Fails Inspector's Signature: _ Date:_AL, The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this.inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the 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, A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,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,cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ►,:;:, PART A ' Qr CERTIFICATION (continued) T - tO t _eA ,,> Broken pipe(s)replaced ,•� Obstruction is removed Distribution Box is levelled 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 FUNCTION- ING 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 water supply or tributary to a surface water supply. i tank and soil absorption system and is with a Zone I of a public The system has a septic to rp y water supply 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 is less than 100 Feet buu50 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than G"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). Number of times pumped -2 :y L1 � e t BORTOLOTTI CONSTRUCTI N, INC. R \` 765 WAKEBY ROAD,MARSTONS MI S, MA 0264 J 508-771-9399 508-428-8926 FAX: 1)8-428-9399 UN 19 9 SUBSURFACE SEWAGE DISPOSAL SYS EM INSPECTION F RM yNOF��9 19 J PART A. l '•} CERTIFIC ION A Property Address: Date of Inspection: Inspectors Name: Owner's Na e a ddress I certify that I have personally i \ad the sew disposal system at this address and that the informa- tion reported below is true, accur to compI as of the time of inspection. The inspection was per- formed based on my training and nce i le proper function and maintenance of on-site sewage disposal stems. The System: he?y Passes Conditionally Passes Needs Further Ev ation to ocal Aproving Authority Fails Inspector's Signature: Date: 1p7 The System Inspector shall submit a. opy of this sp ction report to.the Approving authority within thir- ty(30)days of completing this ins lion. If the sy i is a shared system or has a design flow of 10,000 gpd or greater, the inspector and.t system owner sha bmit the report to the appropriate regional office of the Department of Envir nmental Protection. original should be sent to the system owner A and copies sent to the buyer,if a plicable and the approving uthority. 'INSPECTION SUMM A)SYS'f M PASSES: V I have not fo d any information which indicates Ihat the s ,tem violates any of the failure criteria as fined in 310 CMR 15.303. Any failure criteria t evaluated are indicated below. B)SYSTEM CON IONALLY PASSES; One o ore system components need to be replaced or repaired. The stem,upon comple- tio the replacement or repair,passes inspection. Indicate yes, no , r not determined(Y,N,OR ND). Describe basis of determination in all instances, If not determin " explain why not. T ptic tank is metal,cracked, structurally unsound, shows substantial infiltrati�or iltration,or tank failure is imminent. The system will pass inspection if the existing sep- ti tank is replaced with a conforming septic tank as approved by The Board of Health. ewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - {, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled 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 FUNCTION- ING 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 water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public.. water supply 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 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 pollutiolf from,: the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. . - D)SYSTEM FAILS: 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged 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). Number of times pumped. -2 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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: 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 Il 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check:if the fallowing have been done: ✓Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks and the system,has '!a 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. __p,"As-built plans have been obtained and examined. Note if they are not available with N/A. -_ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. r/All system components,excluding the Soil Absorption System, have been located on site. the septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spSgted for condition of baffles or tees, material of construction,dimensions,depth of liquid, pth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- ' I FS, seµ r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) 1/ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION FLOW CONDITIONS RF.SIDENTLAi: Design Flow: 3 3Q gallons Number of Bedrooms: Nw ber of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readings, ' ailable: Last Date of Occupan COMMER LALIINDUS IAL:Ab Type of Establishment: Design Flow: gallonstday Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: ___ Last pate of Occupancy: s, OTHER: Describe) Last Date of Occupancy: GENE INFORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection:_ if yes,volum pumped: gallons°, Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy . Shared System(If y. ,attach previous inspection recor , if any) Other(explain): AP ROXIMATE AGE of all components,date installed(if known)and source of information: Aa Sewage odors deteco when arriving at the site: -4- xN i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: V concrete metal—FRP—Other (explain) Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: ✓N" Distance from bottom of scum to bottom of outlet tee.or.baffle: /2- Comments: (recommendation for pumping;condition of inlet and outlet tees or baffles,depth of liquid 1 1 in r tion to o let inverts structural integrity, vide a of leakage,etc. / - GREASE TRAP:-A)(-) Depth Below Grade: Material of Construction:_concrete metal FRP Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:—concretemetal FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX.,,I,)(-) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOEL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required,but►nay be approximated by non-intrusive methods) If not determined to be present, explain: Type: / Leaching pits,number: ! Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields, number,dimensions: Overflow cesspool, number: Co nts: (note condition of soil, signs of hyd lic fa' re level o ponding,condition of ve eta ion, etc.4 /UQ'� - CESSPOOLS:-Z;—C) 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:.AA1) Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I'ART C SYSTEM.INFORMATION (conlimicd) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchi larks. Locate all wells within 100 Feet. �I f rO DEPTH TO GROUNDWATER: Depth to groundwater: /1 Feet Method of Determination or Approm tion: /1�,.}'%/�91�'�lzlanl eQ a4 -7- No. Fee_ - i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplicatiou for �Dizpont 6petem Conotruction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot NPOy UAXYM O*C--Tm Owner's Name,Address and Tel.No. Assessor's Map/Parcel 'Q 9 R b 1 d Installer's Name,Address,and Tel.No. 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 Design Flow 3 ® gallons per day. Calculated daily flow 3 L(7:2 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �j�t V Sa` _(LLD Type of S.A.S. A,kjLX65PLcT Description of Soil !ylL70 N: Nature of Repairs or Alterations(Answer when applicable) —_tt K_S_V0A d uG4- L4 ( h� 0►� sm` - Aa l L`t t y�e, 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 Certifi- cate of Compliance has been i s Bo / Signed Date Application Approved b . Date ' s Application Disapproved�foriollowing reasons Permit No. Date Issued i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: . Yes PUBLIC. HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Migaaf *p5tem Construction Permit Application for a Permit to Construct( )Repair(V<Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot Mpoy 6j T1_r O ' rG ti Owner's Name,Addresb and Tel.No. Assessor's Map/Parcel I Gq _. Installer's(Name,Address,and Tel.No. I D€signer's Name,Addlr sand Tel.No. w v t�"F11C'f'C r- Type of Building: a Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �;3 0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank fztc�_S:i r (X0 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ST `\ d w',- L4 (At.• 11 - /411 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 Certifi- cate of Compliance has been ' Bo o:Hea Signed Date —a Application.Approved b -. . LN Date 2. Application Disapproved fort e`following reasons Permit No.. �� r �S Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO SIERM�JJ��Y, t the n-ci 4Se`�age Disposal System Constructed( )Repaired ( )UpgradedrT ( " ) Abandoned( )by K—o _r y l� at has been construct d in accordance with the provis'o s of Title 5 aildjthe f Qr posal System Construction Permit No. °� 02 dated 0 10'57(s/.„ Installer Designer The issuance of thi permit shall not be construed as a guarantee that the syste will function as designed. 1-71 Date Inspector V (^ No. — ------------- Fee �00.7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS MBi!6po5ar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at 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:ConstSuctionpust I a completed within three years of the date of this permit. Date: 612 `/ c7 7 Approved by_ f i' 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 DESIGNED PLANS) IQ� ole 1110S , hereby certify that the application for disposal works construction permit signed by me dated la-at-(-S 7 , concerning the property located at 6O t-J A-e- 0 A,LTrOL i L- meets all of the 1 following criteria: J There are no wetlands within 300 feet of the proposed septic stem e p po p system There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or eater below the bottom of the leaching facility' s e obse g u greater g There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: y / LICENSED SEPTIC SYSTEM 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]. �' .. j' M1 1 ��. D `�� tv` , �` -- r TOWN OF BARNSTABLE i `-- SEWAGE # -- LOCATION t? VILLAG , ASSESSOR'S MAP &LOT INSTALL ER'S NAME PHONE SEPTIC TANK CAPACITY ��ST (size) LEACHIN G FACILITY: NO.OF BEDROOMS BUILDER OR-OWNER PERMTPDATE: 4 -1 N _�J7 J COMPLIANCE DATE: 1� Separation. Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site of within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet .,.,, within NO feet of leaching facility) i Furnished by ' 1.�..-_�—ten..._._...�_ �. _ ____.._...�____ .�_'_��.r...._.��.._... _.�..... ��_• ... ; LEE - --9� 1, / h TOWN OF BARNSTABLE LOCATION �,-,�� �ti/�r'�C ©1n�T�tQ� �--- SEWAGE # 17"3�-'� VJLLA�9EC ASSESSOR'S MAP & LOT INSTALLER.S'NAME&'PHONE*,00.'- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) i wl'�-'►r--!r�' o�� (size) C;) ' NO.OF BEDROOMS BUILDER bk'OWNER- I' ►\- Pro ��E'� .,•. PERMTTDATE: -2+J OMPLIANCE DATE: 4 ���0✓�7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching FacNty 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 `s, �r i m '+ IN . 3 �► �; ® � 1NI �.' YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates [cost$40.00 for 4 vearsi. A business certificate ONLY REGISTERS YOUR NAME in town [which you Main St. Hyannis. a signatures on this form at 200 M y _ permission t--o erate. You must first obtain the necessary g It does give you ermi ) must do by M.G.L. d 9 Y P Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601. (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in please: APPLICANT'S YOUR NAME/S: CL�L�`Z� �LsS/I �i4lL 71 Cdi�7 !2y BUSINESS YOUR HOME ADDRESS: 4• I W. TELEPHONE # Home Telephone Number- `i 2e r kJ bk.1 kl vi tJsf4'd �E,-� 02 020 E-MA I SOC I AL SECURITY OR E I N #: NAME OF CORPORATION: L C NAME OF-NEW BUSINESS z0 TYPE OF BUSINESS 15 THIS A HOME OCCUPATION? k YE NO q � , 4 i c MAP/PARCEL NUMBER l �- -[Assessing) ADDRESS OF BUSINESS. When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — corner of Yarmouth Rd. Main Street) to make sure you have the appropriate permits and licenses required to legally operate your usiness in this town. 1. BUILDING COM S10 .ER'S OFFI MUST COMPLY WITH HOME OCCUPATION This individual ee i or f y p mit uireme is that ertain to this type of business. PULES ANO REGUL.A IOC!$: FAILURE TO COMPLY MAY RESULT IN FINES. th r ignature . OMMEN i I Ciern LAtkl 2. BOARD OF HE , LTH This individual has been in or r d of the permit requirements that pei,tain to this type of business. MUSTGOMPLY WITH AL ., HAZARDOUS MATERIALS REGULATIONS Authorized Ignature** COMMENTS: 1�y- e/-I'll S Ue cf�1�S-7 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the.lidensing requiremepts that pertain to this type of business. Authorized Signature** COMMENTS: i :s TO OF BARNSTABLE L''CA i 10N SEWAGE # 4: VILLA sE ASSESSOR'S MAP & LOT,,20/ S( �" SNAME&PHONE NO. SEPTIC TANK CAPACITY 1006 LEACHING FACILITY: (type) i (size) /0,00 . NO.OF BEDROO BUILDER OR WNER� 1 PERMIT DATE: COMPLIANCE DATE: 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 � T �1 o �S : �C7 '{LOC TION : 5EWIJ,64E PERMIT UO. . VILLAGE IM57QLLE 5 ► WAE ADDRESS - - �a2GH Ya�lS7- — — — — — — BUILDER 5 Q &MF— ADDRESS .MTE--PERMIT_ ISSUED ' D-ATE -CONAPLI L MCE ISSUED : — \\Z'6. '� Off` i I � / ��i , . .... .•---- F t •Fss... ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH __ a VA...... -- ...O F...... A. /. ................................ Apphratiun -for Uispaaoat Works Tonstrurti n Vrruift Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal System at: l ' /1�� 7'pa/ ---------------- �� 10�.. _7------ . ------------_---- -------------- - ---- cation.-Address or Lot No --- - -- - Installer Address Type of Building Size Lot,- .Q Q®......Sq. feet Dwelling—No. of Bedrooms---------- -----------------------------Expansion Attic ( ) Garbage Grinder pi Other—Type of Building ...............'-'-_..'.... No. of persons------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------------------------ W Design Flow............... - --._______--_-_gallons per person per day. Total daily flow_______-3-_��____ _-_-__..---gallons. P4 Septic Tank—Liquid capacity/000_gallons Length................ Width---------------- Diameter-----........... Depth.--___-_:._---- T Disposal Trench—No. .................... Width..._._....__._____ T al Length ......... of leaching area_____-_-..___--_---sq. ft. x �� Seepage Pit No........�----------- Diameter----.� `fie >n�et ---- --- a�I leaching area sq. it. /`" z Other Distribution box ( ) Dosin tank ( ) a Percolation Test Results Performed by. --=---------------- Date---- � _l_ 7.. ---------.-.. Test Pit No. 1----------------mmutes per Inch Depth of "Pest Pit-------------------- Depth to ground water------------------------ (� Test Pit No. Z________________minutes per inch Depth of Test Pit-------------------- Depth to ground water._.--_-----_----,___..-. 04 ------------------------- ......................................................- - ---- Description of So __ 4Aa__. ...�1"'�-i� �------. ------- x ------------ ------------ ------ U Nature of Repairs or Alterations—, nswer when applicable.-.-___......::......._-_-._-__-___-____--__.-__-__.--_-_.._._._---..-_-_-.---__..___-____.... ---------------------------------------------------------------------------------•-------------•--------------•--------------------------- ------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of hea . Sig e � 6..... to Application Approved B �! •-------- --------------------- ----- 7 R----- Date Application Disapproved for the following reasons__________________ __________________________________________________________ _.-••- .................•--•-.......---•-----------•----•--••---------•-------...----------=---------•------•----•----••----------...._......-----•------•----- ............-------•--------.-- ----......... Date PermitNo......................................................... Issued........................................................ Date e" .t- ------------------------ o: •--_. ...... Flz$ ., .... Y = -THE COMMONWEALTH OF MASSACHUSETTS BOARD OF '-HEALTHoF..... ...................... Applirt flog -fur Bi,iplagal Works Tottotrurtintt Vaniit Y 1. ) +-Application is hereby:made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at s- `cat oq Address }y ' or Lot No W n1 : da s .... +' r � -----•-•- Installr Address' A r UType of Building Size Lot_. _ .......Sq. feet Dwelling—No. of Bedrooms.-_ ---_----------------------Expansion Attic ( ) Garbage Grinder aOther—Type of Building ------ """^' "------- No. of persons 4----------------- Showers ( ) — Cafeteria ( ) Q Desi n-Flow............... . "". gallons per person per day. Total daily flow__....._.: ....gallons.• -- Other fixtures -----------------------'_:------- g •-••-----••-•----g• P P P Y• --- Y -•-- R4 Septic Tank—Liquid capacity -0-gallons Length---------------- Width................ Diameter---------------- Depth............ Disposal Trench—No- --------- ----Width._ Total,Length ---. /Tot 'leaching area............_.....sq. ft. I� p }l ie 'islet �.. +'';f a'1 leaching area...... . .......sq. tt. Seepage Pit No_______ ___________ Dtameter.._:. _ e z Other Distribution box'( ) Do tank '-' Percolation Test-Results Performed by elr_er ............. Date- Z x Test Pft'No. L_______________minutes per inch Depth of/,- est Prt..----.-. } .... Depth to ground w<jter...........I;_---.. .. LT, Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground 'Water- ----------------- Descrt non of --------------------- Soil ( �p 4 /� J�:�} Y2' ,� ,} y�1• `,�7d ,,y�y� Wf t i`-vt 6 S } { �. iL r 9 Vf 4�b. ... �.. y� M M _..:A /P .. UNature of Repairs-or Alterations—Answer when applicable......__ ._._ .,, ____ __ ____________________________ __ __._._..... . .r .- -- Agreement The undersigned figrees to install the aforedescribed Individual Sewage Disposal. System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of'-Compliance has been issued by the board of he lth. S' tC�L ism .t2-,rC `�to tgned-_ y Y } ate Appltcatton Approved BY f I'j A *' �'�t'+ q Lea. .. . ................................ _ _�______ ... _____. ' Date .Application Disapproved for the following reasons:--------.. - --------------------------------------- - ............. r -•--•--------------------•----- Date Permit No.....................................= Issued - Date ti rl i THE COMMONWEALTH OF MASSACHUSETTSr BOARD OF HEALTH . .................o F.... ...�" ..:..:.:. . Uprrtifirate of f�1anmpliaurr THIS 'S,T" "�CERTIF,#I That the In uidual ew Disp -al System constructed ( or Repaired -.- �. ,,�r��+•' Inst111er, f Air ) has been installed in accordance with the provisions of ArtRle XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit Nod 7.4----------_--- .................. THE ISSUANCE OF THIS CERTIRCATE SHALE. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .• y DATE ----------------•-•---------------••••••••-•--•--•--•------• Inspector......................................... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD- OF. HEALTH, ' No...... FEE.- ----! -6-- .. i �i����ttl rk� ��t���trttrti�tt err it Permission is .hereby gr anted___.. _._--._ 1 -.- :..: ... . ...C -.... c ................ to Construct 411) or Repair}(/ ) n Indiivtdual Sewage�DtsposalISystem t,, w 'street . as shown'on the application for Disposal Works Construction Permit,No c:....... Dated....' '� _7- --.- �p' y -----• ------. Board of Health DATE--- a—/ -------(ol-------------------------•----------------------- . •^ t FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS •t t t , t ' i '/_ 14le et Z')� a pcdc. •ill o V'4'_.. }. e 9 � 1f -A id71 t 'AHH� f 75/ 9 o Po1G nr77 - o5 W Ch ro ` 1 ,, V 1` �Y t -VI //D . 7 Oake. l u C A� R