HomeMy WebLinkAbout0900 SHOOTFLYING HILL RD - Health 900 SHOOT FLYING HILL RD.
CENTERVILLE
`- A = 192 051
AS
UPC 10259
No.H,6 30R �►, s�'
NA�TINO�,.YN
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
�A �2 0/ �.
DATE:% � Fill in please:
' # APPLICANT'S YOUR NAME/S:
BUSINESS YOUR HOME ADDRESS: O t�
.- e t rvi�;e o v 2c� 2 y` `
r r TELEPHONE # Home Telephone Number .�O — /
NAME OF:.CORPORATION
NAME OF NEW BUSINESS S TYPE OF-BUSINESS
1S THIS A HOME OCCUPATION? YES N
ADDRESS OF BUSINESS U0 hUc31 IVl l Ieiwl l� 1�11� MAP/PARCEL NUMBER ��2 i (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.
r
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any mit requirements that pertain to this type of business.
D
Authorized Signature*
COMMENTS: o0 Qe 1 2 e Sb .
2. BOARD OF HEALTH
This individual has ppee,lr for (/d of the permit requirements that pertain to this type of business. MUST�,OMPLY WITH ALL
KATF
Authorized Signature S �' _- . AT.
**
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: I/
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: 11- r? /1.r'✓PV7— 106,VD 159 Mj
BUSINESS LOCATION: 900 1 lemo-f INVENTORY
MAILING ADDRESS: (?UCI ��Gu �/�i/�►� l� TOTAL AMOUNT:
TELEPHONE NUMBER:
CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE NUMBER: C5b3) -737 r7Z 0 MSDS ON SITE?
TYPE OF BUSINESS: &rjCV11V,e1
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
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils V Pesticides ( %C)
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas /
Photochemicals(Fixers)
r(CA^"j4-S ❑ ❑NEW USED
Diesel Fuel, kerosene,#2 hating oil
Miscellaneous petroleum products: grease,
Photochemicals(Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives(creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers Qn 69)5e
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous(please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash C �( e1'►Z°
WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS pplicant's Signat re Staff's Initials
. r
COMMON«EALTH OF MASSACHUSETTS
EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECT ]
TITLE 5
OFFICIAL INSPECTION FOR VI—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION,
Property Address:. XV .�
Owner's Name: ,, e '
Owner's Address: `� RV�ica we�
RECEIVED
Date of Inspection:
NOU 2 6 2001
Name of Inspeg or: lease print H' ` G 'P`-t'
Company Nan ll . - �Y�"� • TOWN OF BARNSTABLE
]Mailing Address:. HEALTH DEPT.
Telephone Number: �Or'. `�`7/c-
CERTIFICATION STATEMENT
I.certify that I have personally inspected the sewage disposal system at:this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance.of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340.of Title 5(310 CMR 15.000). The system:
/Passes
Conditionally Passes
Needs.Further Evaluation by the Local Approving Authority
Fail f
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
DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1 i
V
Page 2 of 1 1
OFFICIAL-INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A .
CERTIFICATION (continued)
Property Address:
ILVIA
Owner:
Date of ns 'ction:
Inspection Summary: ;Check A,B,C,D, E/ALWAYS complete all of Section D
A. S stem Passes:
I have not found any information which indicates that any;of the,failure,criteria described;in 3.10=CMR
t5.303 or in 310 CMR 15.304 exist.Any.failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the'Board of Health,v,ill 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 Nvith 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
obstnicted pipe(s)or due to.a broken;settled or uneven distribution box. System Nvill pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstr6ction is removed
distribution box is leveled or replaced
ND,explain:
The system required pumping snore than'4.times a year due to broken or:obstnicted 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:
2
Page 3 of 1'1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTI:J,M INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: �1
Owner:
Date of luspection.: f T
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 pasninless Board of Healt►rdetermines in accordaiiee witli 310 CMR 15'3Q3(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 l of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_.The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a
private water supply well".Method used to determine.distanc6
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppin,provided that no other
failure criteria are triggered. A,copy of the analysis must be attached:to this form.
3. Other:
3
Page 4 of I I
OFFICIAL.INSPECTION TORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ✓ `'
Owner:
Date of Ins ection: y �7/o ff
A System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the,following for all inspections:
Yes N
Backup of sewage into facility or system component clue to overloaded or clogged SAS or cesspool
_ Discharge or.pond.ing 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 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.
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 coliform bacteria and volatile organic compounds
indicates that the well:is free from pollution from that facility 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 forma
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a:large'system the system must serve a facility with a-design flow of 10,000 gpd to.15,000
gPd•
You must indicate either"yes"or"no"to°each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
.the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply'well
If you have answered"yes"to any question in Section E the system is considered a significanrthreat,or answered
"yes" in Section D above the large system;has failed. The owner or operator of any large system considered a
sieni6.cant threat under Section E or failed tinder Section D shall upgrade the system in accordance with 3.10 CMR
15.304.The system owner should contact'the appropriate regional office of the Department.
4
i
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART B
CHECKLIST
Property Address
Owner: -
Date of Ins ectior►: 1-716
Check if the following have been done.You must indicate"yes"or"no' .as to each of the following:
Yes o
Pumping.inforniation.was provided by the owner,occupant,or Board of Health
V 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?
— 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)
V — Was the facility or dwelling inspected for signs of sewage back up
f — 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 s- - o cum?
j,/ _ Was.the facility owner(and occupants if different from owne,r).pro.vided 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:
Yes no
V 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 CMR 15.302(3)(b))
5
Page 6 of 1 I
OFFICIAL INSPECTION,FORM=NOT FOR VOLUNTARY ASSESSMENTS
'SUBSURFACE SENNIA:Gr DISPOSAL SVSUA INSPECTION FORM
PART C
SV STI,M INFORMATION
Property Address: &6e'IAS
Owner:
Date of ns ction: /7 ` Q
TLOAv CONDITIONS
RESIDENTIAL
Number of bedrooms(:design):1-115—. Number of bedrooms(actual):
DESIGN flow based on 310 CvIR 13.2(f3 (for example: 110 gpd x#of bedraoms):
Number of current residents:
Does residence.have.a garbage grinder(yes or no):2..
Is laundry on a separate sewage system (yes or no)• [if yes separate inspection required)
Laundry system inspected(yes or noL.
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or o):
Last date of occupancy: J �
COMMERCIAL/INDUSTRIAL 0-
Type of establishment:
Design flow(based on 310 CMR.I5.203): gpd '
Basis of design flow('seats%person's/sgft,'etc.);
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:,
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:VJ Al Jklp-lly"" VIV,;,A-7.1,
Was system.pumped as Part'ofthe i specti .(yes or no):
If yes, volume pumped:.< gallons==Tlow was quantity pumped determined?
Reason for pumping:. .
TYPE OF SYSTEM
_j. Z8'&ptic 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)
—Tight tank _Attach a copyof the DEP.approval
Other`(describe):
Ap ro iI ate age of all components,date installed(if known)and source of information.-
Were sewage odors'detected when arriving at the site(yes or noL-a&—
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VO,,.LUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMAAT/ION (continued)
Property Address:
Owner:
Date of Insp etion: J// 4:;z /Q/
BUILDING SEWER(locate on site pla"elf—'
Depth below grade:
Materials of construction:. cast iron _40 PVC_other(explain):
Distance from private water supply well or,suction line::
Comments(on condition of jointsi venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade:
Material of construction: concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:— I's age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) .
Dimensions:la :K(�°�
Sludge depth! /,ok. /� /
Distance from top of sludge to bottom of outlet tee or baffle: Z�
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 1 pR
Distance from bottom of scum to bottom of outlet tee or baffle'. Z ��
How were dimensions determined:
Comments(on pumping recommendations, i let and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.): L
®'
GREASE TRAP: A[ Jseate onaite plan) `�' n ,
Depth'below grade:'_"
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
Page 8 of I 1
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYS I EM INFORMATION(continued)
Property Address: =/"L ���
✓�, 'fie►
Owner:.
Date of In pection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments (condition of alarm and float switches,etc.):
DISTRIBUTION BOX: V (ifpresenf!mustbe opened)(locate on site plan)-
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
,4takage into or out of box,etc.): „
U.
PUMP CHAMBER: (locate on siteplan) .
Pumps in working order(yes or no):
Alarms in working order(ye's-or no)-,�
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE_DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(yntinued)
Property Address: 9-0
D
Owner: A;e�q
Date of Ins ection:
SOIL ABSORPTION SYSTEM (SAS):. ✓(locate on site plan,excavation not required)
If SAS,not located explain why:
Type
—zleaching.pits, number:
leaching chambers, number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.): v
aue ,e dc.We :4 U/A
CESSPOOL�S (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 or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding,•c6ndit on ofvegetation;:etc.): .
PRIVYlocate 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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSUI iNACE SEWAGE DISPOSAL SYSTEM INSPECTION FO1gM
PART C
SYSTEM INFORMATION(continued)
Property Address:.
A III
��
Owner:
Date of Ins ection:
P
11/f'7,/12./°
SKETCH Or SE'NAGE 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 106 feet. Locate where public water supply enters the building.
yp9
ire
10
Page. I I of 1.1
OFFICIAL INSPECTION FORTH—NOT FOX VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address:10,92a
Owner:
Date of *pect1i&on:
SITE EXAM,
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to ground water Z`� feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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:
;AVM � oJ'a �
�^
I1
Permit Number: Date:
—
l[::L<.:::::it
Completed by:'
— ,
-fill
s HIGH GROUND-WATER i
H GR. C-W'ATER LEVEL COfJIPl1THTlONi
Loc Site Q �
ation:'
� /fI i Lot No.
X t�.
Owner: �/
���t _ �f �f ,/�'�L�✓/-61 Address: J�
;ter,. Contractor: / /12. / _640W,` —Address:
t Notes:
fib';t i
STEP 1 Measure depth to water table to nearest 1 10 ft. ...................:................................................... . .Date
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well..................:.....................:..........: I�lwy
OWater-level range zone .....................................................�J
STEP 3 Using monthly.report "Current
Water Resources Conditions
determine current depth to
water level for index well
Mont /Year
STEP 4 Using.Table of Water-level Adjustments
for index well (STEP 2A), current death
to water level for index well (STEP 3),
and water-level zone (STEP 23)
determine water--level adjustment ............................................:............................................. i
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) .......:......:.......................
Figure 13.—Reproducible computation farm.
'0.-00
02-14-2000 08::31AM CENT CST FIREDEPT 508?902385 P.02
mane appltcatton to local Me vejJdr d M1114-
t� Pare Department retains original application and issues dupficate as Permit.
lug-,
��?`Lt7iY-G��'YL6'lZGO��Ulr2 V '1�'ULCP,b— ✓UPGY!���J'G.� ✓ ?�2d�'l���Z
APPLICATION and PER MITF�:
for storage tank reirmval and transportation to approved tank disposal yard in accordance vAth the provisions
of M.G.L. Chapter 148_Section 38A, 527 CMR 9.00, application is hereby made by:
MUST M-
r..,..
Tank Owner Name(pier�z print) Dan Gallagher X
SOnaNro N-V y,ng W pdmvt
Address 49 Tellegen Trail, Centerville, HA 02632
S~ Cuy — °eare ZP
Advanced Environmental Advanced Environmental
Company Narne _ Co.or individual
� Prrnr Pm!
Address P.O. Box 472, S. Dennis Address
Pdnr ��� Prnr
Signature if plying itr_ermr---j Signature(if appiyin erm,t)
.= IFCt C2rtfw- Other w IFCI Certified _5= 'Other
Tank Location 900 Shootflying Hill Road, Centerville
-— wav<Addms --- r
Tank Capacity(galicrts; 1,000 Substance Last Storms- #2 Fuel 011
r
Tank Dimensions(diar x length)
Remarks GV�
Firm transporting waste Advanced Environmental State Lie, : MV5083856100
Hazardous waste mar%s 4 _ ;.P.A.#
Approved tank disposaf-ead J.G. Grant Tank yarn# _ 008
f
Type of inert gas ?ankyard address Wolcott Stxeet, Readville, MA _ I
City or Town Centerville FD[O* 01920 _Permit#
—�
February 10, 2000 February 24, 2440
Oate cf issue _ _ ___Da,te of expiration
Dig sate approval numi*r 20000704851 Oig Safe Ycp Tel.Number-860.322.4844 I
Signature I Title of Cffi-- ganting permit
After removals)send For, ?•290R signed by Local Fire Dept, to UST Regulatory Cornpliamz Unit,One Ashburton Place,
Room 1310,Boston.MA• 0&1618.
TOTAL P.02
.c. .. «..... i
�.. i�
Y `� v r�s
I
9 p '_fIq
1�
RO EO
FEB 1 5 2000
` t0.Z�EripSTkE b
COMMONWEALTH OF MASACHUSETTS 4,
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 900 SHOOT FLYING HILL RD. CENTERVILLE CENTERVILLE, MA MAP 192 LO E)I
Name of Owner PATTI RAFORD
Address of Owner: C.O BOB SHIELDS 49 TELEGRIN TRAIL CENTERVILLE MA.
Date of Inspection: 1/20/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15,000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET MA.02636
Telephone Number: 608-664-6813 FAX 608-564-7270
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The Inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
_ Passes
_ Conditionally Passes
X Needs Further Evaluation By the Local Approving Authority .
Fails
Inspector's Signature: Date:2/11/00
The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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.
NOTES AND COMMENTS
"The inspection Is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
Inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE INSPECTION NEEDS FURTHER EVALUATION FROM THE BARNSTABEL BOARD OF HEALTH.THE SYSTEM IS IN THE BACK YARD.THE
SYSTEM CONSISTS OF A SEPTIC TANK AND TWO PITS.SNAKED LINE OUT TO ONE PIT AND IT APPEARS TO BE TOUCHING THE POOL.THE
D-BOX IS ROTTED.
revised 9/2/98 Page 1 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 900 SHOOT FLYING HILL RD. CENTERVILLE CENTERVILLE, MA MAP 192 LO
Name of Owner PATTI RAFORD
Date of Inspection: 1/20/00
INSPECTION SUMMARY: Check A, B, C, Or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are Indicated below.
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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination In all instances.If"not determined",explain why not.
n/a The septic tank Is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance
attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,
whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The
system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health.
n/a Sewage backup 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).
_broken pipe(s)are replaced
_obstruction is removed
X distribution box is levelled or replaced
nLa 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
revised 9/2/98 Page 2 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 900 SHOOT FLYING HILL RD. CENTERVILLE CENTERVILLE, MA MAP 192 LO
Name of Owner PATTI RAFORD
Date of Inspection: 1/20/00
FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
X 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance n!a(approximation not valid).
3) OTHER
ONE LEACH PIT IS TOUCHING THE EDGES OF THE POOL.
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 900 SHOOT FLYING HILL RD. CENTERVILLE CENTERVILLE, MA MAP 192 LO
Name of Owner PATTI RAFORD
Date of Inspection: 1/20/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
- X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
- X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
- X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
- X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
- X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Il.
- X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X. Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X 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:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
_ X the system Is within 400 feet of a surface drinking water supply
- X the system is within 200 feet of a tributary to a surface,drinking water supply
- X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 108 COLONIAL DR. FALMOUTH, MA 02540
Name of Owner: PATTI RAFORD
Date of Inspection: 1/20/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X - Pumping information was provided by the owner,occupant,or Board of Health.
X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.
Large volumes of water have not been introduced into the system recently or as part of this inspection.
X - As built plans have been obtained and examined.Note if they are not available with N/A.
X - The facility or dwelling was Inspected for signs of sewage back-up.
X - The system does not receive non-sanitary or industrial waste flow.
X - The site was inspected for signs of breakout.
X _ All system components,excluding the Soil Absorption System,have been located on the site.
X - The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of
construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been
determined based on:
X - Existing Information,For example,Plan at B4O,H,
X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
revised 9/2/98 Page 5 of 11
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 900 SHOOT FLYING HILL RD. CENTERVILLE CENTERVILLE, MA MAP 192 LO
Name of Owner PATTI RAFORD
Date of Inspection: 1/20/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual):
Total DESIGN flow: 440 gpd
Number of current residents:n/a
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: 111/99
COM MERCIAUINDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping:n/a
TYPE OF SYSTEM
X 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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date Installed(if known)and source of information:
1976
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2198 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 900 SHOOT FLYING HILL RD. CENTERVILLE CENTERVILLE, MA MAP 192 LO
Name of Owner PATTI RAFORD
Date of Inspection: 1/20100
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 24"
Material of construction: _ cast iron _ 40 Pvc X other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER;THE SEWER PIPE IS 20 PVC
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 24"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: L 8'6"H 6'7"W 4'10
Sludge depth: 8"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness: 12"
Distance from top of scum to top of outlet tee or baffle: 24"
Distance from bottom of scum to bottom of outlet tee or baffle: 0"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
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.)
n/a
revised 9098 Page 7 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 900 SHOOT FLYING HILL RD. CENTERVILLE CENTERVILLE, MA MAP 192 LO
Name of Owner PATTI RAFORD
Date of Inspection: 1/20/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: Na
Capacity: n/a gallons
Design flow: n/a gallonstday
Alarm present: NO
Alarm level:WA Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
THE DISTRIBUTION BOX IS ROTTED AND NEEDS TO BE REPLACED.
PUMP CHAMBER: _
(locate on site plan)
Pumps In working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2/98 Page 8 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 900 SHOOT FLYING HILL RD. CENTERVILLE CENTERVILLE, MA MAP 192 LO
Name of Owner PATTI RAFORD
Date of Inspection: 1/20/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-Intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(2)LEACH PITS
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PITS APPEAR TO BE FUNCTIONING PROPERLY.THE PITS SHOW NO SIGNS OF FAILURE.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a Inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9098 Page 9 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 900 SHOOT FLYING HILL RD. CENTERVILLE CENTERVILLE, MA MAP 192 LO
Name of Owner PATTI RAFORD
Date of Inspection: 1/20/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
P4 I
lil 4
6
4A iy
B ail
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 900 SHOOT FLYING HILL RD. CENTERVILLE CENTERVILLE, MA MAP 192 LO
Name of Owner PATTI RAFORD
Date of Inspection: 1120/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
NQ Obtained from Design Plans on record
NQ Observed Site(Abutting property,observation hole,basement sump etc.)
NQ Determined from local conditions
NQ Checked with local Board of health
NO Checked FEMA Maps
Na Checked pumping records
NQ Checked local excavators,installers
X Used USGS Data
c
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
flWNE'�
LOC&.TION LOf l0 5EW&64E PERMIT QO.
D1 21LI
VILLAGE /77
- - - - - - - -
Ih1STQLLER 5 1 &ME ADDRESS
i
BUILDER 5 Q L VAF- ADDRESS
ANTE PER"1T
D ATE COMPLI &&ICE ISSUED ; - - -
alp
7����� 4/ o ,8o x
asp
No.....��---- _-- (.�.... ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O , HEALTH
l
qoo Appliratinn -fur Uhiv fiat Workii Towitrnrthin Prmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal,
System att: a
.`G �_ �. ...... T� -------- Ce
--'Wiz.` -
Location-Address or Lo .
Owner
,a
Address
n - ----------� �
er Address
UType of Buildings Size Lot-.�=... �' _SSq. feet
.-, Dwelling I-No. of Bedrooms.-.----�-----------------------_-----Expansion Attic ( Garbage Grinder
per., Other,Type of Building -------------- ----------- No. of persons----�----------------- Showers ( Z..�-- Cafeteria ( )
A'' Other fixtures ---------------------------------
W Design Flow__- _-_ gallons per person per day. Total daily flow.......... ....................gallons.
WSeptic Tankd1 capacity6_ allons 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 ( ) �9 4 ...-
� �e� —
aPercolation Test Results Performed by---------------------------------------------------------- ---- Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
l4 Test Pit No. 2................minutes per inch Depth of Test Pit.------------------- Depth to ground water-----.-.---------------.
--- ------ -�--- -�7 -�------------------�-`-'-��` ..--- ---__ _Description of Sotl------........
x -
W
-----.W_ . ' ------f44
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en issued by the board of health. w
gned. � .'.
Date
Application Approved By......... . A------------- � Date
Application Disapproved for the following reasons:................................................................................................................
------------------------------------------------------ -------------------------------------------------.----------•------------------------------------------•-- --------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
- --._- ---------------------- —--------—-------------------------------------------------- -------------
�J
No......
Fa$... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
.--------OF...... .... . .. ...Cl i. ................_..........................
Aplrltration -for Mapoiittl Eorkii Towitrurtion Vrruiit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systemlat: `
............................................I + U �e!r j •.._ + j G �-�r e! � . +<L�r-•'•J........•-•---------
Location:Address " or L t
j Owner Address
.............•-•-•--VsI• O.R.l.�=J L/l ! .�. 5 ...........-----••-• C.....2 !�/ _
Installer Address
UType of Buildings Size Lot-----— ___.... q, feet
Dwelling�; of Bedrooms--------11------------------------------Expansion Attic (�c�" Garbage Grinder ( �
`.4 Other—Type of Building ------•-------------••------ No. of Persons..___ ................. Showers Cafeteria
( )
dOther fixtures -------•------- -----------------------•-•-------•---
W Design Flow _� ----------------------------gallons per person per day. Total daily flow........... .�"V....................gallons.
WSeptic 'Tank ....Liquid capacitd_�___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 ( ) :�,9 t�-
aPercolation Test Results Performed by----------------------------------------------------------------------•-•- Date..............---•----------•-------
Test Pit No. 1................minutes per inch Depth of "Pest Pit..._--_.._____----_. Depth to ground water.._._.-----.---._.-..._.
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....-.-.-_-___-_---__.._
P4 --------------- =
Description of So' .-_.U______-_ �h -toLA,! 4____._�_!4_ _ ._-._ ______ ___.................... __----
f -
// {/./G!!/1a......W,/ �E` - --..... CGstf_•- -------------------- ---•-------
W
V 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issued by the board of health.
date
Application Approved BY--------- r'1• � =----------- -----
Date
Application Disapproved for the following reasons:-------------------------------------------'--------- ••-•---------------•----------•-•---. --------------
-----------------------•--.-----•---------------------•-------------•-•----------•------•-•-•-•------------•---------------------.--•-•--•--•---------------------------------.--------------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.OF...........
Tntifirate of Tomplialtre
TH2IS] TO CERTIF , That the Individual Sewage Disposal System constructed ( or Repaired ( )
bY... C ___
Installer -
has been installed in accordance with the provisions of : t' 1. XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-7 ......., __y --------- dated.._--- _
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................--------------••-.............. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
/ BOARD OF HEALTH
71O � . ............. ...... � OF............. .. .... 1 ....
FEE._. (./.............
Di-spatial ork �o trtirtiott drrZatit
Permission is hereby granted._:7:!t-_. ...... r ^
to Construct or Repair ) an/In vi' al Sewage Dispdg�l tem /
at No._. ?. r/=- lt..,; _y .. "�- UU���� ------- ..... {-.-' J'{- �=l�
--- --
street
as shown on the application for Disposal Works Constru tion r it No. _______________ D
Pated._-.__....gyp__-.� �-'-- -
�r
G.r Boar of Health
..--
DATE---. --"' !--�----------7 ------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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B Gl/iG4OW 5T >0,0"O U 77/P0Q7 MA.
y .. .-...-7 r Fis..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...........OF... i. ...... ... --•..... ......................................
ApplirFation for Disposal Works Tnntitrnrtion rantit
Application is hereby
made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system
yst -..1" -----•.......... ...... . --------- .. -----------..----------.-----
cation--Ad� No.
ner Address
........ -- . -• --•-- . ....... ...-�................... ------• 1.!l/,._............__... .....•..•.•.^-.._.._....__.
Installer Address
Type of Building Size Lot..--.l "M-Sq. feet
Dwelling—No. of Bedrooms............. ..........................Expansion Attic 440 Garbage Grinder (/ 6
pa, Other—Type of Building ............................ No. of persons.....................--..... Showers ( ) — Cafeteria (oey6
Otherfixture,--------------------------------------------------------------------------•-----------------...-.----•---------•---•-----------------•---•-----------
W Design Flow............. ....................gallons per person per day. Total daily flow........'-r. .................gallons.
WSeptic Tank—Liquid capacity-.I ...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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ..................................................................
...
.............
...
-...
....
--------
--------------
------------
-------------
••----
0 Description of Soil..........................................................................-----------------------------------------------------------------------------..........--•---
W
---
•-----
•-----------------------
-------------------------------------------------------------
--------------------------------------------•----------------------------------------•-----------
W
UNature 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 L ITLI 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operatpn,Zfftil a C tificate of Compliance has been issued by the bo !d of h 1
Signed-- ------ ------- . �r
Dat
Appcation Approved By..................................... ...... ... ...........................................
Dal
�
Application Disapproved for the following real ns......-•----•-•-•.................... --•---•--•--
••--••-•..............................•-••--•.....----•-•................................... ...................................................
......--•------•..-----------•--•--•-•••--•-------
Date
PermitNo......................................................... Issued.......................................................
Date
�. =ai
No.. .
�'...-7 g Fxs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................... OF.
" l/P S /!+1 !� �c
Appliration for 3lispaa al Works Tonstrnrtinn "permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address r 1 " or Lot No.
" f f Owner ' Address
Installer Address
d Type of Building Size Lot....Z"�....--ZO..Sq. feet
Dwelling—No. of Bedrooms............._..............................Expansion Attic Garbage Grinder ( Ay c>
a`4 Other—T e of Building _....___.... No. of persons............................ Showers
YP g --------•-•----- P ( ) — Cafeteria (��)c
Otherfixtures .------•----•--•-------------------•-•------•-------.-•-••••-•-•--•-••-•••-••--•----------------•-•••----•---•-•--••-••--•-•-•--•----...-•-...--•---
WDesign Flow............ .. .....................gallons per person per day. Total daily flow-----._... ..:r .?..................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........................
a -••••••---•-•--•----•--•----•-•---••••••------••....................•---...............................................•-••••••----••-•--...........•--.--•--
0 Description of Soil-------------------------•----.....---..........----•--•--------...-----------•------•--------------------------------••-----------•------••--•-•--••-••---•-------....
W
V ....•-••-••••••••-••-••-•-••-•-••----•••--•••-•...--••••-••---••--••-•••-------•---•....•••....--••_......-•-•-••••-•--•----•---•-•••---•----•-•-•-•----•••--••-•---••••-•-••.....................•--••-
W
UNature of Repairs or Alterations—Answer when applicable.........................................................................0......_........_.....
-•------•----------------------------------------------•----------------•--....--------••-•-----....--•-------------------------•-----------•---•------•-•--...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation til a Ce tificate of Compliance has been issued by the board of h f .1
�✓ !"� Signed .................
Dat
A cation Approved B _ : �^
PP PP Y .b
Dat
APPlieation Disapproved for the following real ns.....................................................................................
.................................................................................
Date
PermitNo.......................................................- Issued.........................----------------.............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......)..........!� OF.....: 1. ,",...c:j.%...::.......r.<!..........................................
TatifirFatr of TiampliFanrr
THIS IS TO CERTIFY T at he Individual Sewage Disposal System constructed (X) or Repaired ( )
by .... ................•.... •--••••••-•••••--••-----•-•----•----------.................•••....----------................
Installer
at-----------------------------------------L o.+.......6,?.a.............. ' ------- .x.Z nt'----...
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code des ibed in the
application for Disposal Works Construction Permit No........ ........... dated_--.-_____. ----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR NTE THAT THE
SYSTEM WILL_FUNCTION SATISFACTORY.
Zv
DATE. :.:.............................................•----...._•---- " Inspector_........................--••••------•---...._-••...-•-----•--...............•-•-•• F
A = 17O " M THE COMMONWEALTH OF MASSACHU
% PERVISE
®EFj�„��NG ENGINEER
BOARD OF HEALTHNSTALLATIO AND CERTIFY IN WRITING
THE SYSTEM WTAI_ED IN STRICT
OF............................................. O �PLA
No....n(1.72 F . .1._!�..........
Biipao al 10ork.5 T. nntrnrtilan amit
Permission is hereby granted....................... ..............!P-Aae�.p.....•.......................................................
to Construct ( ) or Re air ( ) an Individual S :wage Disposal stem
0 {
r..... `i2 y2X
Street �`
.as shown on the application for Disposal Works Construction Permit No.__ ............... Dated....... _ _�. ..�. ......_..
------------------------------------------
7 ea ........----
DATE....................1.
FORM 1255 A. M. SUL IN INC.. BOSTON ,,,.
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.. . 74
BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131
WILL IAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering
August 6 , ' 19'86
Town of. Barnstable Board o'f health
P .O. Box 534
Hyannis , MA 02601
RE,: Lot 682• Seth Parker Road, 'Centerville
Installer : Robert Our
Applicant : Alan Small
Gentlemen :
In accordance with your request, I have inspected
the installed septic system at Lot 682 . Based upon
visual inspection, the system has- been installed in
accordance with the approved plan.
I trust that this meets your present needs .
Very •truly yours,
Peter Sullivan, P , E .
Baxter & Nye, Inca
PS/bc
CC ; Alai. Small
�Vjv% OF 414,V .
PETER y�
SULLIVAN
CJ
NO. 29733
0
/STEa4.
FSSIONA t ENG�O
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS