HomeMy WebLinkAbout0040 WINDLASS LANE - Health q LOT #13 40 WINDLASS LANE, CENTERVILLE
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.
A. General Information ]
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
,w- V- sewage,disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
6� Title 5.(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
r�w
❑ Needs Further E uation by the Local Approving:Authority
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7-7-10
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
I
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40 windlass Centerville•03l08 Title 5 Official Inspection Form:Subsurface Sew4Disp System•Page 1 of 15
ti
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working with no sign of failure..
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND)in the ❑ for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound,�not•leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years'old-is--available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
40 windlass centerville•03/08 Tittle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is'leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the-SAS is within
100 feet.of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
40 windlass centerville•03108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® 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 '/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:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
40 windlass centerville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No .
❑ ® 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. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.-
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ E the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"-.to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
40 windlass centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 16
Commonwealth of Massachusetts
- Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is Centerville MA 02632 7-6-10
required for every
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
I
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CM 15.302(5)]
40 windlass centerville•03/08 Title 5 Official Inspection Form:subsurface Sewage Disposal system•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
i Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 7-2010
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
40 windlass centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is
required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? -
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
40 windlass centerville•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 36"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition.
Septic Tank (locate on site plan):
Depth below grade: 30"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1500 gal
Sludge depth: 12
Distance from top of sludge to bottom of outlet tee or baffle 20
Scum thickness 0
6-
Distance-from top of scumto top:of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tape
40 windlass centerville•OWN Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
40 windlass centerville-03/08 1Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M
40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions: ,
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
40 windlass centerville•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'w 40 Windlass Ln M '
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2-36'x4'x2'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition.of
vegetation, etc.):
Leach trenches in good condition with no sign of back-up or break-out.
40 windlass centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Windlass Ln
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
40 windlass centerville•MOB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Windlass Ln
'M
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
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40 windlass centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a 40 Windlass Ln
M
Property Address
Alan Simoneau
Owner Owner's Name
information is required for every Centerville MA 02632 7-6-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 10'.
I
40 windlass centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
Hazaydous Materials Inventory Sheet Checklist
t/ Date
Physical Street Address-Check database to ensure it exists
._'Working Phone Number
�L Actual Amounts—(i.e.gas being used to fuel machines,thinner to
clean brushes all count as hazardous materials)
Storage Information—location of storage,how long is storage for?
f none,note that.
Disposal Information—where and who? If none,note that.
Applicant Signature—understand what is listed and noted.
Staff Initial—any questions,know who to ask.
Vehicle Washing/Rinsing?—provide a vehicle washing policy and
explain it—note that it was given.
Attach the Business Certificate with your sign-off and comments.
"The Inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them
(/ J TOWN O1~BARNS'TA.BLE
.00ATION T� VL° �+ 4 S� `� SEWAGE #'
1YLLAGE ��`� f e�J.:l le ASSESSOR'S &LOT
NS3;,L ER'S NAAM&PHONE NO.
;E171C TANK CAPACrrY 15S()D _
.FACkiING'pAOIH.I'I`Y: (size)
10.OF'BEDROOMS y
MILDER OR OWNER
IERMITDATE: COMPUANCE DATE:
separation Distance Between the:
rlaximurn Adjusted Groundwater Table to the Bottom of Leaching Facility Eect
'tivatc Wator Supply Well and Leaching Facility (If any wells exist
on site or within 20,0 feet of leaching facility) ee;4
lldge of Wetland mid Leacigng Facility(If any etlands'exist
within 300 feet f leaching fuci�V)/
-urnishcd by._1-5,�,,,41 /UI = v
31.
- o c
1�
TOWN OF BARNSTABLE Date: /U / /7 A
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: *A.
BUSINESS LOCATION: 40 41Indlass L-Cnc C'err[Arville 03.43), INVENTORY
MAILING ADDRESS. 1 ,d •0®-� 1313 Qnnis A. 41.6,01 TAL AMOUNT:
TELEPHONE NUMBER: go r'a"d,
-J a- �1t 11(6 '
NTACT PERSON: _
�AERGENCY CONTACT TELEPHONE NUMBER:
d -�Ly'���� MSDS ON SITE?
TYPE OF BUSINESS: C I-cr, _1n tr ILLS
INFORMATION/RECOMM DATIONS: Fire District:
Waste Transportatio Last shipment of azardous waste:
Name of Hauler- Destination: Aft A
Waste Product: 140u a r® Licensed? Yes No
NOTE: Under the provisions of Ch. 111, ection 31, of the General Laws of MA, hazardous materials 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) Misc. Corrosive _
NEW USED Cesspool cleaner p
Automatic transmission fluid DisinfectantsA cc
Engine and radiator flushes Road Salts (Halit
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbici es, ro&�tici&'�s)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fix s)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. 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 Misc. 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 (inc. carbon tetrachloride)
- NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor& furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
6 Laundry soil & stain removers NIA
(including bleach)
6 Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
I Windshield wash
WHITE COPY-HEALTH DEPAR ZCANARYCOP)Y-BUSINESS
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates (cost $30.00 for 4 years.) A Business Certificate ONLY REGISTERS YOUR NAME in iry
town (which you must do by M.G.I.- it does not give-you permission to operate.) You must first obtain the necessary signatures on
this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL., 367 Main Street, Hyannis, MA 02601
(Town Hall) and get the Business Certificate that is requi ed by law.
n 4 Fill in please: Date: JQ / 0
M APPLICANT'S NAME:
MR �a.5 r r S
?* �
'7- W�7 . YOUR HOME ADDRESS: �Q W rnelcsS Lane,
t BUSINESS TELEPHONE 30Q g0 A rig HOME TELELPHONE # 30 3L4 Iii
.s
NAME OF CORPORATION:
NAME OF NEW BUSINESS 70S{ h (R. iraS C eanln� pri�r� C�a�l TYPE OF BUSINESS(
IS.THI$ A HOME OCCUPATION? YES NO
ADDRESS OF BUSINESS CIO G1i last 1�anj (�r}{cryillt M A 0a43), MAP/PARCEL.NUM BE (Assessing)
When starting a new business there are several^things you must do to be in compliance with the rules and regulations of the Town of
Barnstable. This form is to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth Rd.
& Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH
This individual has en informed the pe requirements that pertain to this type of business.
PLY NTH ALL
tfibrlied Sign u * HAZARDOUS MATERIALS REGULATIONS
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHOR TY
This individual V b en infq e0•of the .n i r �ements that pertain to this type of business.
Authorized Signature**
COMMENTS:
l
a
I 6 •t~'Z - 9 �6s - 9
Z104 - h E 916B - /7
al �
a-J-
TOWN OF BARNSTABLE
LOCATION o L
VII.LAGE C SEWAGE #
f!L ASSESSOR'S MAP& LOT ` /9 2
INSTALLER'S NAME&PHONE NO. 0 19
SEPTIC TANK CAPA L
cIIY /s-o o C-
LEACHIIVG FACILITY: (type) 2 LF o '
i RIC �r u srsize) 34
NO. OF BEDROOMS _
BUELDER OR OWNER
PERMITDATE: 2-/6-
COMPLIANCE DATE:— 7- /-7 Separation Distance Between the: 9
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facili Feet
on site or within 200 feet of leaching facility) �any wells exist
Edge of Wetland and Leaching Facility within 300 feet of leaching facility)
(If any wetlands exist Feet
Furnished by
Feet
RICHARD J. JUDD, R.S.
Professional Sanitarian
775 Freeman 's tray
Brewster , Massachusetts 02631
(508) 896-8615
July 201 1998
Mr. Gerald Gunning'
Health Director
Torn of Barnstable
367 Main Street
Hyannis, MA 02601
Res Certificate of Substantial Compliance
Mark Franciosi
40 Windlass Lane
Centerville, Massachusetts
Dear Mr. Dunninq:
As per your request and in accordance with 310 CMR 15.021 (3) of the D.E.P.
State Envoronmental Code, Title 5, I am addressinq this correspondence to
you directly regarding the abode captioned Project. I hereby Certify that
the existing Sanitary Subsurface Sewage Disposal System has been installed
in Substantial Compliance with Design Plan by Richard J. Judd, R.S.
If I can be of any further assistance to you on this matter , please do not
hesitate to contact me.
' Respectfully submitted,
Richard J. Judd, R.S.
a
No. r _3F e Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Mgpogai &pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 2 Complete System ❑Individual Components
Location Address or Lot No. Lot 13, 40 Windless Lane Owner's Name,Address and Tel.No.
Assessor's Map/Parce Centerville, MA Mark E. Franciosi
]Plan Book 236 Page 127 49 Amos Road, S. Yarmouth, Ma
Installer's Name,Address,andjel.No. 912 J' �7 Designer's Name,Address and Tel.No.
C ��' „t✓G "7 Richard Judd, 775 Freeman's Way
c •70--,q 04)6 �� F Brewster, MA
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size 15,001 sq.ft. Garbage Grinder W
Other Type of Building 1 story, sing, of Persons / Showers(2 ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date 4 ,,;, :?,' Number of sheets Revision Date
Title
Size of Septic Tank z5-00 Co Type of S.A.S.12 Y VAI X Z
Description of Soil See :2
NING ENGINEER WRITING
INSTALLATIO INSTALiD IN STRICT
,, Mature of Repairs or Alterations(Answer when applicable) THE
^wE1(M�CW�{AS
ACCORDANCE6 ,
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 s tem in operation until a Certifi-
cate of Compliance has been issued b this B and Health.
Signed Cl- Date
Application Approved b _ Date. `
Application Disapproved for the following reasons
Permit No. _ Date Issued
TOWN OF BARNSTABLE -a °
LOCATION o W;.) LeS'S LA4e., SEWAGE # 9S7 - 3 06
VILLAGE C c,,,`?"e��, y tLLe ASSESSOR'S MAP & LOT -� �9®9 q
INSTALLER'S NAME&PHONE NO. R g tao 141 S LJG 77F-0 y 1/y
SEPTIC TANK CAPACITY l S-0 d G 5"T "
LEACHING FACILITY: (type) Z LE4okIA"),9 `rfir#J_a9Msize) 3C'x
NO.OF BEDROOMS
BUILDER OR OWNER 1AA iA A k 1C AAJC_J oS%
PERMITDATE: rI-/c~ 4r COMPLIANCE DATE: % J'1 IF
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
L6
9
z
No. Fee/ f'n 4171 �
THE COMMONWEALTH OF MASSACHUSETTSEntered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEf` MASSACHUSETTS Yes
Application for 3ME;pooal *p$tem Con$truction Permit
r � Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 19Compiete System ❑Individual Components
Location Address o4ot No. Lot 13, 40 Windless Lane
Owner's Name,Address and Tel.No.
Assessor's Map/Parce Plan Book 236Centerville, MA Mark E. Franciosi
,, Page 127 49 Amos Road, S.:-Yarmouth, Ma
Installer's Name,Address,al Tel.No. Designer's Name,Address and Tel.No.
�� �� Richard Judd, 775 Freeman's Way
Brewster, MA
D.v 06
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size 15,001 sq.ft. Garbage Grinder(J✓r
Other Type of Building 1 story, singjg0. of Persons / Showers(2 ) Cafeteria( )
Other Fixtures `
Design Flow to d 4 a e gallons per day. Calculated daily flow ,y yy gallons.
Plan Date A- Number of sheets Revision Date
Title
1
Size of Septic Tank /S'a 0 a s Type of S.A.S. 6 L X VAI X Z P
j�
Description of Soil 7/RFA/C Y e.V
Sic .7/lari
Nature of Repairs or Alterations(Answer when applicable)
4 V
l
Date last inspected:
Agreement: 4
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 gstem in operation until a Certifi-
cate of Compliance has.been issued by this Board Health.
_ s Signed
S gnV Date
t
APPlication Approved by
- s rs �
� A plcationrDisapproved for the,following reasons
Permit No. E Date Issued '� y�
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired( )Upgraded ( )
Abandoned( )by
at D 1W has been Construc d ' acc rX cge
with the provisions of Title 5 and the for Disposal System Construction Permit N dated
Installer Designer
The issuance of this permit shall not a construed as a guarantee that the system wil function as designed.
Date - / - Inspector
------- -----Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
MiOPOMI *Pe;tem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at 40 Windless,Lane, Centerville, MA
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 permit;
Date: - / - / Approved by Q
1°` l
i Zoning Classification °�
-CO OCU
Zone: RC Zoning
_ o
EXISTING SEPTIC SYSTEM '
RESERVE LEACHING AREA CB/Disk Min Front Setback 20' a � x
FND per 1998 As—built,
40' X 10' X 2' Health Department' Records, Min Side Setbock 10' oia GoQc• o�ca
444—GPD /0 0, o #98-306 Min Rear Setbock 10' sf°9
0
S 7 O' , c
o•
�? 42 E
1
Deed: Book 24,720, Page 157
'7 Plan: Book 236, Page 127, Lot 13
CB/Disk �� LEGEND
FND
0, o� , - - • - - - - - Existing Building
�, Edge of Driveway
rram�, Q q
�1 CL � OS CV �J �e Overhead Utility Lines
Ij�
sir r� jco CBNDDH e Electric Meter
IT
' � �. ��� F gm GoMeter
•ha7 Overhang 1? 1' 11. a `'r u 00 �P rti
0� // t r
w °� r L
= per own r e � Q` � � LL �0�p�L�1
le car
0
Q .Patlo
„o , PROPOSED POOL
1
00 IV) - See Plan b Shoreline Pools, Inc.
d• ONV em 4 y
9m
o) M . ONO
l� H EXISTING SHED 1-
� Q ONv LOT 13 3 to be Felocoted
15,001 sFt o PROP05ED CONDITIONS PLAN
ce/DH or 0.34 Acf
o ;0
FND 1 ,, 40 Windlass Lane
126.
'w Barnstable (Centerville), MA
N 79'18730" h/ o J David and Carolyn Tinsle
ASSESSORS RL SHEEL
19-079 SHEET i
Existing Patio $ �ZH OF -NK OF ttgs DAM' EROMP
to be removed �`� S$4, ��'� s9Qy 09/26/2019 19-157
o� MICHAEL ti� ° RICHARD G
SCALE: 1"=20' or modified �� S. J. �
0 20 40 60 Potential Shed i DUE C JUD J . �' Moran Engineering Associates, LLC
Re—location ation o. 375 941 Route 28 N PO Box 183
e
o �P ✓ �G/ F South Harwich, MA 02661
0 2019 Moran Engineering Associates, LLC lgNO UR.���� SgNiTAR�P� 508-432-2878
foP of.fo
calf iron
sch. -40 P v,
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prop. f ir7. con-four o o---
- rest hole location , -�-
L /';I A P
5c�9Z_E:
_ 1
1 2 3 4 5 6 7 8 9 10 11 12
REVISIONS
REV ZONE DESCRIPTION DATE:
A A
55'
BREAKFAST
NOOK
B OUT B
BEDROOM
MASTER BEDROOM
LIVING ROOM
00
C f 00 KITCHEN o C
010
BATH
0Li
CLOSET
38'-6„
T`1 MASTER
BATH
BEDROOM
LAUNDRY
40 HMO, 51 ' o O O DINING ROOM OUT
lz
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E E
rn
GARAGE 18
F F
0
21 '
No. REQ. PART No. DESCRIPTION REMARKS
G LIST OF MATERIALS G
FLOOR PLAN THESE DESIGNS AND SPECIFICATIONS ARE NOW AND DO REMAIN THE PROPERTY
OF HEGER DRY DOCK, INC. USE OF THESE DESIGNS OR REPRODUCTION OF THESE
DESIGNS WITHOUT OUR EXPRESS WRITTEN PERMISSION IS PROHIBITED.
SCALE: 1 /4"=1 '—O" CLIENT HEGER DRY DOCK, Inc.
DRY DOCK ENGINEERS
DESIGN,INSPECTION,DIVING AND CERTIFICATION
PROJECT
13 WATER STREET
HOLLISTON, MA 01746
(508)429-1800
TITLE
40 WINDLASS LANE
H PROJECT DATE
0000—D 05 30 11 H
CEN TER VI LLE MA
CHECKED BY SCALE DRAWING UNITS
M. PROCTER AS NOTED INCH FLOOR PLAN
SUPERVISOR CAD FILE NAME SHEET SIZE
R. HEGER 0000-00-00-00 D-22 x 34
DRAWN BY DIMSCALE LTSCALE DRAWING No. 0000-00-00-00 SHEET 1 OF 1 ISSUE A
J. HOBART 48 18
1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4 5 6 7 8 9 10 11 12
REVISIONS
REV ZONE DESCRIPTION DATE:
A A
2X4 WALLS 16" O.C.
R-13 INSULATION
W/VAPOR BARIER
B SEE DETAIL A—A B
SEWER PUMP
4' SHOWER STALL
O EXISTING
o HEAT AND
HOT WATER
C BATHROOMce
C
0
MEDIA CENTER
POOL o
TABLE 830 SQ FEET
6'—0"
D D
UNFINISHED
2'-8"
AREA Cs
o BAR
O o 0
O
OUT
UP
E E
0
DETAIL A- A
SCALE: 3/4"=1'—O"
F F
BASEMENT FLOOR PLAN
SCALE: 1 /4"=1 '—O"
No. REQ. PART No. DESCRIPTION REMARKS
G LIST OF MATERIALS G
THESE DESIGNS AND SPECIFICATIONS ARE NOW AND DO REMAIN THE PROPERTY
OF HEGER DRY DOCK, INC. USE OF THESE DESIGNS OR REPRODUCTION OF THESE
DESIGNS WITHOUT OUR COMMWRITTEN PERMISSION IS PROHIBITED.
CLIENT HEGER DRY DOCK, Inc.
DRY DOCK ENGINEERS
DESIGN,INSPECTION,DIVING AND CERTIFICATION
PROJECT
13 WATER STREET
HOLLISTON, MA 01746
9--% (508)429-1800
TITLE
40 WINLASS LANE
PROJECT No. DATE
H 0000—D 05 30 11 CEN TER VI LLE MA H
CHECKED BY SCALE DRAWING UNITS
M. PROCTER AS NOTED INCH FINISHED BASEMENT
SUPERVISOR CAD FILENAME SHEET SIZE
R. HEGER 0000-00-00-00 D-22 x 34
[DRAWN BY DIMSCALE LTSCALE DRAWING NO. SHEET OF ISSUE
J. HOBART 48 18 0000-00-00-00 1 1 A
1 2 3 4 5 6 7 8 9 10 11 12
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