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HomeMy WebLinkAbout0126 ARROWHEAD DRIVE - Health A_ ' 126 ARROWHEADDRIVE, HYANNISOEM A- lz f I' 0 o I x i JC TOWN OF BARNSTABLE LOCATION 1A-UDW SEWAGE # % 7?V VILLAGE wvt,Q S ASSESSOR'S MAP & LOT d27I- 121 INSTALLER'S NAME&PHONE NO. 0 -4, SEPTIC TANK CAPACITY I j dp S. 1 t LEACHING FACILITY: (type) h Lcr/IiCr7 �-,rV (size) .3Q2!5 YZY NO.OF BEDROOMS BUILDER OR OWNER IN O _- PERMITDATE: t Z-3 i - eI .7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ' � � � �_ S�' ®� �� . - ,� 7 � Y + + � � � ,�� � � � a � � � i • I TOWN OF ARNSTABLE LO�;ATION ,�a� SEWAGE # a4A�,'_o rVILLAGE ASSESSOR'S MAP & LOT' `f I//,Zt INSTALLER'S N &PHONE NO'.' SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist;,. within 300 feet of leaching facility.) Feet Furnished by r 9 W w 1 Uj - a ILII Hazardous Materials Inventory Sheet Checklist Date h Physical Street Address-Check database to ensure it exists Working Phone Number n Actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials-no blanks) Storage Information -location of storage, how long is storage for? If none, mote that. n Disposal Information -where and who? If none, note that. i _Applicant Signature - understand what is listed and noted _ f) _Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and explain it j 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. YOU WISH TO OPEN A BUSINESS? r " For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE:O. 16 Fill in please: N Jn �`'� APPLICANT'S YOUR NAME/S: tit 0N Z� ' AlL S,'� ' � BUSINESS �9 YOUR HOME ADDRESS: �615 TELEPHONE # Home Telephone Number ,r 4'•'i�s Fes'?•,A�Fn3..r� NAME OF CORPORATION.dj t�� r ;r� ,, �, �, ,- �.d - _ a•; y:; .F�,,,* - y.. NAME OF NEW,BUSINESS ;k N t ` " + TYPE OF BUSINESS A "(� / _� a , , IS THIS A`` M HOE OCCUPATION? YES' NO ADDRESS OF BUSINESS" `- MAP PARCEL NUMBER` =l lZ Assessin ( 9)' When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COYMISSIO ER'S Te T�a This individ qI in per it requirem nts that pertain to this type of business. µ - ut oriz i nat ** - OMMENTS: r i o 2. BOARD 0 HEALTH This individual has een ip�firrpedlof the permit requirements that pertain to this type of business. • //V 1/t V i MIIS'f COMPLY WITH ALL Authorized Signature** HAZARDOUS MATERIALS.REGULATIONS. 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: R, i r. Date: 31 k, TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS - NAME OF BUSINESS: gAi4�x d E-G- / _ 77E -T 6-0 BUSINESS LOCATION: (! l _ Al- a INVENTORY MAILING ADDRESS: 6At(nzi;; .�t0 0( -W- 6 TOTAL AMOUNT: TELEPHONE NUMBER: J 50%) 540 216,9 CONTACT PERSON: ( o lr'1 LA)Cra-f '�7>00 LA EMERGENCY CONTACT TELEPHONE NUMBER: �50S) 36 5 64014 MSDS ON SITE? TYPE OF BUSINESS: �'Imo;AJ Q 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) (D Miscellaneous Corrosive 0 ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants �) Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) n lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&'garages Wood preservatives (creosote) (10 Caulk/Grout tU Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Q Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners U (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison"labels (including chloroform, formaldehyde, Paint,&-varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel � Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS App icant's Signature Staff's Initials Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Arrowhead Drive Property Address v Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. Cityrrown - - - State Zip Code Date of Inspection- Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ► �� on the computer, use only the tab 1. Inspector: - - key to move your cursor-do not Ricky Wright use the return key. Name of Inspector B & B Excavation,Inc. �y Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 . Cityrrown State Zip Code 508-477-0653 S 14595 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 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 ❑ Fails ❑ Needs Further Evaluation by the Local:Approving Authority E i �- 2/7/13 . 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,.ifapplicable, 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. �Iv� li 3 l5ins•11110 Tide 5 0 Miecon Form:Subsurface Sewage:Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. Cityrrown 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: 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): �+(Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 • ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•1r1/10 �.* / Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments M 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: t ElThe 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. ❑ 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 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 must be attached to this form: 3. Other: I D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No El ® 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow t5ins 11/10 !4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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. I 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. i 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 ❑ ❑ 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. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Arrowhead Drive Property Address.. Peter Monteiro Owner Owner's Name information is Hyannis MA 02601 2/6/13 required for every y page. Citylfown 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 El ® 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ® 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 breakout? ® ❑. . 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 CMR 15.302(5)] D. System.Information Residential Flow Conditions: -. Number.of bedrooms(design): 3.. Number of bedrooms(actual):. 3 . DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments M 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. Cityrrown State Zip Code Date of Inspection t D. System Information Description: Number of current residents: 0 t 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: I Sump pump? ❑ Yes ® No Last date of occupancy: Sept 2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank present? ❑ Yes El No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•,11/10 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information i Pumping Records: Source of information: 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. l ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 1/2'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 1 1/2'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: no sludge t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. 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 `t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 F r r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. Cityrrown 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.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: r I ' ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: A I Capacity: gallons 3 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.): �" 1 `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name n information is required for every Hyannis MA 02601 2/6/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): At time of inspection d-box appears to be in good condition. Pump Chamber(locate on site,plan): ` Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 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: i i l5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. City/Town State Zip Code Date of Inspection M System Information (cont.) , Type: ® leaching pits number: 1 ❑ 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.): At time of inspection leaching appears to be in working condition.Water level 1' below invert. No sign. of hydraulic failure Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert _• r Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is Hyannis MA 02601 2/6/13 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): I t5ins 511/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i ..:.Commonwealth of Massachusetts Title 5 Official Inspection Form ~'Subsurface Sewage Disposal System Form - Not for Voluntary'Assessments. 126 Arrowhead.Drive Property Address Peter.:Monteiro Owner Owner's;Name information is required for every. Hyannis . MA 02601 2/6/13 page. .City/Town State Zip Code Date of Inspection D: Sy- stern.lnforma#ion (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: hand-sketch in the area below E- drawing attached separately . � I �2 35 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 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: feet 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 97 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: Before filing this Inspection Report, please see.Report Completeness Checklist on next page. .t5ins 11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Arrowhead Drive Property Address Peter Monteiro Owner Owner's Name information is required for every Hyannis MA 02601 2/6/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I l5ins .11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migpogal *p$tem-CO gteUCtion Permit Application for a Permit to Construct( )Repair(grade( )Abandon( ') Complete System O Individual Components Location Address or Lot No..r uo Y we Owner's Name,Address and Tel.No. Assessor's Map/Parcel Q-1 �"' �•.� dV•j�t tf' Installer's Namee,Address,and Tel.No. -!?�r. 6e Designer's Name,Address and Tel.No. t- Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building - No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. _ Plan Date Number of sheets Revision Date ' Title Size of Septic Tank'l C _OD S C , Type of S.A.S. Z c Description of Soil &r_4a Nature of Repairs or( Alterations(Answer when applicable)..:Z�J 1 �C�� J��t�� �'�f GDP Jr,�✓✓- �'C� (� C.�i..�f/.i�"�i y�J1�`CJ��t/41i� f.L� `-1 I U� J�W�J Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued hy this B Signed Date �C Application Approved by Date - Application Disapproved for th fo lowing ieasons Permit No. Of ' 7 Date Issued ^�.•. ..w/ Y". ems--,..�• ...: '.�.,. �... -.. -..� .- ;-->:< . .,-. � ...__ .. . :`r-.+•-- .•fix .-•"r- i No. ^,fP,,y Fee .THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes - " PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplication for Mtgo.5al *p!5tem Con!gtructton permit Application for a Permit to Constrict( )Repair Grade( )Abandon( ) Complete System ElIndividual Components (� Location Address or Lot No.1 }e r we Owner's`Name,Address and Tel.No. �. '•.Assessor's Map/Parcel .L tl/ -e X7rGl V, Installer's Name,Address,and Tel.No. '7-1 -6 6�y Designer's Name,Address and Tel.No. °A J Q-`a �5 ZO J 2c M"Q Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building ` No.of Persons Showers( ) Cafeteria( ) Other Fixtures `Design Flow gallons per day. Calculated daily flow 3 yC7 gallons. Plan Date Number of sheets Revision Date A Title Size of Septic Tank l SOb T} e ofjS",ArS-:- t Description of Soil Nature of Repairs or Alterations(Answer when applicable). 1 1 75co 5a 0 Date last inspected: ' x 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 nato place the system in operation until a Certifi- cate of Compliance has'been issue is B ` } c Signed �� Date 10 Application Approved by Date-� a.- 3/- �7 Application Disapproved for th following reasons Permit No. 7 - 7 Date Issued - —------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS t f. 1 1 Certificate of Compliance THIS IS TO gERTIFY, that the On-site Sewage Disposal System Constructed„( )Rep ued( )Upgraded(t/S F Abandoned( )by 6 �}kJ21�t�4C-A (Jt\J . I b_ ca 10 at 4-A Z 12..I"W AC-w 4TtU JC- L/A N S has been'constructed in accor anee with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall hot be construed as a guarantee that the system will function as designed. Date f `h R Inspector f i' .. - .. _ .-- - .. .. .. .. . . .. --. �� r No. 7— L Fee 'THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Moogal *potem C w5tructton Permit Permission is hereby granted to Construct( )Repair( [�Jpgrade( )Abandon,(. ) System located at 0 �. >\�:W 1q 1Z� J C ; �"��'� ka � S 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: 1 4­3 :2 Approved by !S� 1019/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic,Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) i hereby certify that the application for disposal works construction permit signed by me dated concerning the located at (, A �(�( -fie :� � h�meets all of the property following criteria: v There are no wetlands located within I oo feet of the proposed leaching facility �/. There are no private wells within 150 feet of the proposed septic system /There is no increase in flow and/or change in use proposed zonere are no variances requested or needed. /. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will n-W be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) _ B)Observed Groundwater Table Elevation(according to Health Division well map) 2 SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan or the proposed system.Also If the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert '►," '.a (' _•� TOWN OF BARNSTABLE . CATION SEWAGE # VILLAGE ASSESSOR'S MAP& LOT 7 - IIV$TALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 r LEACHING )~AGILITY: (type) r} -aztLc (size) NO.OF BEDROOMS BUILD' FR OR OWNER n,Aa PERMITDATE:_ 2- 1 - cf 7 COMPLIANCE DATE: Separation Distance Between the: Maxittium Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist. oil or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet ------------ h . + ♦ w r r { }�i' -+•+-# 4- t-1'- # t t-+ + +-w +•t #- '}- t'+•t # 4 ? +•.-+ + '+ t d a r r . ♦ e f t • 4 , .a + # � � � +.r { � � 1 a.:w,.+ 4 40. � 1 i i + .�.--.4.++..i. ,y..._.i.a.e�.}•�•+•�.- :^+i .,..yi,-�a,. .'4,_.} ..-+•_-i._-.r-1-JY--'}--i•- ->..,.-+'-•--T.:.. ;-_a.��.� • •}�:+ - ter•.---t•--�, i-_o -r'-►=+.-t. �.•.. .}- i-- +-'►-`.''' i+.w--. -.-.�..-a..+- -v�-F'-i +' .i.._-..-a�,F-•t.�--i^.-.�. . -t.......,1...� �-�•f....},...+.o ,.� - - w�-•a ,-,'L�- ,-.t-- -1--i-- .-•t-'^t-_•.•. - r_.F..•-._ -1 --,r..y.}+..�-t ..}. t +_+..,� # �,. � .-t t- - + + �._� -t-+ +.T={� 1 t ♦ t.i + Y s�•»-#_^� _r . 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