The URL can be used to link to this page

Home My WebLink About0148 ARROWHEAD DRIVE - Health ,148`•ARROWHEAD DR. , HYANNIS A = 270,153 I ° a ° o ° I I a ° . a 4 TOWN OF BARNSTABLE C- . L ' LOCATION / SEWAGE # ` VILLAGE /V 11.4,ya.4 c ASSESSOR'S MAP &LOT / / i 3 INSTALLER'S NAME&PHONE NO. � Q SEPTIC TANK CAPACITY / ( e D LEACHING FACILITY: (type) / 14 7R/}1Dt-(� (size) C NO.OF BEDROOMS BUILDER OR OWNER PERMrrDATE: COMPLIANCE DATE: 1 �/ 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 L Tvf i t �. e i � � .�. ':� . . ��1 .' C �� to r • ` t� � . i • r W t� �_ � � � t �► �� {� r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments y 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name information is required for Hyannis Ma 02601 3/27/2007 every page. Cityfrown State Zip.Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any j way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises LLC Company Name f Q P.O.Box 763 Company Address ICI Centerville Ma Zip 32 Co Citylrown State Zip Code (508)428-4028 Telephone Number License Number B. Certification 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 Section45.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails (n C--)1 -71 Needs Further Evaluation by the Local Approving Authority (7 ry r- _..- fT1 3/27/2007 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use.. 148 arrowhead dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15. 1 � Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary•Assessments 148 Arrowhead Drive Property Address t Evelyn Reed ; Owner Owner's Name information is required for Hyannis Ma 02601 3/27/2007 every page. Citylrown State Zip Code Date of Inspection 1 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. r ' Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by. the Board of Health, will pass' Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection.if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance.indicating that the tank is less than 20 years old is available. ND Explain: t 0 I 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 ' E J: ❑. obstruction is removed 148 arrowhead dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 115 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name information is required for Hyannis Ma 02601 3/27/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: , C) Further Evaluation is Required by the Board of Health-- Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated`wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a_manner that protects the public health,. safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 148 arrowhead dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5' Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name ! information is required for y H annis ` 't Ma 02601 3/27/2007 _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.)• ` C) Further Evaluation is Required by the Board of Health (cont.): r ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or i more from a private water supply well". ' ' Method used to determine'distance: + **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or, less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be . attached to this form. 3. Other:" 1. D). System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: + Yes No t , 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• t due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded y or clogged SAS or cesspool s r :"El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ® Required pumping more than 4 times in the last year NOT due to clogged or El obstructed pipe(s). Number of times pumped: ` ` ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. k Any portion of cesspool or privy is within 100 feet of a surface water supply or ® tributary to a surface water supply. isposal System 148 arrowhead dr.•08106 Title 5 Official Inspection Form:Subsurface Sewage D System'-Page 4 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name information is Hyannis Ma 02601 3/27/2007 required for y every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence_ of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® 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. 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. 148 arrowhead dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Arrowhead Drive Y Property Address Evelyn Reed Owner Owner's Name information is required for Hyannis Ma 02601 3/27/2007 - every page. Cityrrown 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: ' i Yes No l c a ` ❑ ® 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? ❑t ®. Have large volumes of water been introduced to the system recently or as.part of this inspection? ® ❑ Were as built plans`of the system obtained and examined? (If they were not available note as N/A) _ ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank - inspected for the condition of the baffles or tees, material of construction, ` dimensions, depth of liquid, depth of sludge and depth of scum?' s ® Was the facility owner(and occupants if different from owner) provided with. information on the proper maintenance of subsurface sewage disposal systems? t 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)] t ` - 1: r '148 arrowhead dr.•08/06 / Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name information is required for Hyannis Ma 02601 3/27/2007 every page. Cityrrown { State Zip Code Date of Inspection 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 Number of current residents: unknown { Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required]' ❑ Yes E. No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No " Water meter readings, if available (last 2 years usage (gpd)): 2005- 2006:157'000 Sump pump? ❑- Yes' ® 'No unknown Last date of occupancy: 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? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No . r _ 1 Non-sanitary waste discharged to.the Title 5 system?, ❑ Yes ❑ iNo Water meter readings, if available: , Last date'of occupancy/use: Date Other(describe): 148 arrowhead dr..08/06 + Title 5 Official Inspection Form:Subsurface Sewage,Disposal System-Page 7 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name information is required for Hyannis Ma 02601 3/27/2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises . Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: r 1500 gallons How was quantity pumped determined? Measured Reason for pumping: Heavy solids in tank. ' Type of System: z 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) ' El maintenance technology. Attach a copy of the current operation.and maintenance contract(to be obtained from system owner) ❑ Tight ftank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: ` System installed in 1999 Were'sewage odors detected when arriving at the site? ❑ Yes ® -No 148 arrowhead dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name information is required for Hy annis Ma 02601 3/27/2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1'6 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic.Tank(locate on site plan): 1' Depth below grade 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 ------------------------------ ------------------------------------------------------------------------------------------- 10'6"x5'10"x5T' Dimensions: none Sludge depth: t Distance from top of sludge to bottom of outlet tee or baffle na. Scum thickness none Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? tank pumped 148 arrowhead dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 148 Arrowhead.Drive Property Address Evelyn Reed Owner Owner's Name information is required for Hyannis Ma 02601 3/27/2007 every 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.): Pump tank every 2-3 years.Inlet and outlet tees are in place.Tank appears structurally sound.No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction:' ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 148 arrowhead dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 f Commonwealth of Massachusetts v Title 5 0fficial I Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Arrowhead Drive Property Address 1 Evelyn Reed Owner Owner's Name information is Hyannis Ma 02601. 3/27/2007 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.). Tight or Holding Tank(cont.) I Dimensions: Capacity: gallons Design Flow: L , gallons per day - •, j Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes( ❑ No Date of last pumping: t' r Date y Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): ' Depth of liquid level above outlet invert No 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.): Box is level and has one lateral.No evidence of solids carryover.No evidence of leakage into or out of box. � r r Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No �. 148 arrowhead dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 / Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name information is Hyannis Ma. 02601 3/27/2007 required for y every page. Cityrrown State Zip Code Date of Inspection r D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators ❑ 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.): Sandy soil.No evidence of hydraulic failure.No ponding or damp soil. 148 arrowhead dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name information is Hyannis Ma 02601 3/27/2007 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l � 148 arrowhead dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name information is required for Hyannis Ma 02601 3/27/2007 every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide.a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 6acl�• • yb�� ys, I 148 arrowhead dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Arrowhead Drive Property Address Evelyn Reed Owner Owner's Name information is required for Hyannis Ma 02601 3/27/2007 every page. Cityrrown 1 State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar 4 ❑ Shallow wells r. Estimated depth to round water: fee p g - feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record I If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: as-built card ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: ' You must describe how you established the high ground water elevation: Used:Gahrty& Miller model 12/16/94 ground water elevations.Used:USGS observation well-data June 1992.Used:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. r r. i .', 1148 arrowhead dr.•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G:L.-it does not give you.permission to operate.) Business Certificates are available at the Town Clerk's Office, 1�`FL., 367. Main Street, Hyannis, MA 02601 (Town Hall) DATE: ®%A 171 O G Fill in please: - APPLICANT'S YOUR NAME: m� BUSINESS YOUR HOME ADDRESS: \4'Z ' TELEPHONE # Home Telephone Number SO'% —t 1$ t410Cz. N NAMEIIF NEW BUSINESS_ EQ: 1. '� PE:OF BUSINESS ►� �' � .. IS THI,SA HOME OCCUPATIONS YES: NO Have you been.given approval from the!buil m divisions YES NO ADDRES;SOFIBUSINESS � �e. Q -. QGC.Y�SS [s CtS MAP/PARCELN.UMBER When starting a new business there are several things you must-do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to.assist you in obtaining the information you may need. You MUST GO TO 200 Main St.. (corner of Yarmouth Rd..& Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been-informed of any permit requirements that pertain to this type of business. Authprized Signature* COMMENTS: 2. BOARD OF HEALTH This individual Mn i b ed of the ermit re uirements that pertain to this type of business. Auth iz Signature* r r COMMENTS: 3. CONSUMER AFFAIRS LICENSING AUTHORI This individual ha n infor of the lic n re irements that pertain to this type of business. Authorized Signature* COMMENTS: Date: O\ .C)e TOWN OF BARNSTABLE �/ / TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: N:�IYC'Q ZC- MRI a NA-0,1 E RK-SP&R BUSINESS LOCATION: INVENTORY MAILING ADDRESS: SICK \S33 V\4Auu\S EAA 0-260 t TOTAL AMOUNT- TELEPHONE NUMBER: 5m L- koC� CONTACT PERSON: M\CHA-I C \kc1ER- EMERGENCYCONTACTTELEPHONE NUMBER: 501 —t \`I ?_Sl Z MSDS ON SITE? TYPE OF BUSINESS: 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 materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants O Engine and radiator flushes Road Salts (Halite) O Hydraulic fluid (including brake fluid) Refrigerants Motor Oils ® Pesticides NEW USED (insecticides, herbicides, rodenticides) O Gasoline, Jet fuel, Aviation gas O Photochemicals (Fixers) 0 - Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, O Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink O Degreasers for driveways &garages 0 Wood preservatives (creosote) O Caulk/Grout 0 Swimming pool chlorine O Battery acid (electrolyte)/Batteries O Lye or caustic soda Rustproofer.s O Misc. Combustible O Car wash detergents d Leather dyes 0 Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varniis-he-s_,�tains, dyes J��C _ Other chlorinated hydrocarbons, 0 Lacquer thinners (inc. carbon tetrachloride) NEW USED O Any other products with "poison" labels 0 Paint &varnish removers, deglossers (including chloroform, formaldehyde, 0 Misc. Flammables cf) hydrochloric acid, other acids) Floor & furniture strippers bOterodu is t listed which you feel O Metal polishes to c hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents O. Bug and tar removers d Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS No'. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Miopooal *potent Conzt uction Vermt,t _ ; Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System &ilvidual Components Location Address or Lot No. AQLOUAV�!4(_ U4127 Owner's Name,Address and Tel.No. Assessor's Map/Parcel `v �/� w Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ck� v% vlS 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 s gallons per day. Calculated daily flow s �Ss gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1/ Type of S.A.S. 4,C Description of Soil; 1l1tVr { • .: ,mot ' Nature of Repairs�or Alterations(Answer when applicable) 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 be o ea c igned Date 0_`!C�`J C` Application Approved by Date iZ—(y - 9 s Application Disapproved for the lowin reasons Permit No. 2�9- 1R Date Issued ( TOWN OF BARNSTABLE -- LOCATION l!ik A AAaLu;U ow A SEWAGE # ASSESSOR'S MAP &LOT VILLAGE INSTALLER'S NAME&PHONE NO.� �:`'^ °'" CPT*� i SEPTIC TANK CAPACITY I LEACHING FACILITY: ( . i NO.OF BEDROOMS i BUILDER OR OWNER IAI�1 1 COMPLIANCE DATE: PERMITDATE: . i Separation Distance Between the: IMaximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet . Private Water Supply Well and Leaching Facility (If any wells exist Feet on site 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 17 , • No. — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS'? ' 01ppftcatton for Mtopogar *p5tem Conot uction VernUt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon(� ) Complete System individual Components Location Address or Lot No. 1 y�(j �k(Z`L(�V�V�—�(�(�� l� Owner's Name,Address and Tel.No. Assessor's Map/Parcel _' \J J? Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1.. s V'As S`C c-,0"VCcS Type of Building: X ci 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 If Size of Septic Tank Type of S.A.S. / . Description of Soil�Ait.P�L`S�4;A . � n Nature of Repairs or Alterations(Answer when applicable) (2( (SI-yjC 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 Me bee al c ignS�edssa Date Application Approved by Date Application Disapproved for the lowin reasons Permit No. ��' 1- P L4 Date Issued THE COMMONWEALTH OF MASSACHUSETTS . BARNSTABLE, MASSACHUSETTS Certificate of (tomphance �� i 4� THIS IS TO CERTIFY,that the-0 site Sewage Disposal System Constructed( j Repaired (��`�SUpg�r'aded Abandoned( )by i n, — Pk:_ S IB t 'L < / t / 'r at y : rhas been construc"ted,'A accordance with the provisions of Title 5 and the for Disposal System Construction ermit No. - dated Installer Designer J n/ n The issuance of this permit ha 'not bi cons ed as a guarantee that the sy,etn will functiotn�as/e igne/Iv Date vl Inspector . I JiU 1 i � X No. — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migozaf Opaem Conotructton Vermtt Permission is hereby granted to Construct( )Repair( )Upgrade(Abandon( ) . System located at "Wo f Y t rP 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//byye completed within three years of the date of this permit. Date: Approved by i 1/6i99 NOTICE: This Form Is To Be' Llsed For the Repair Of Failed Septic Systems Only., CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT rWITHOUT DESIGNED PLANS) I, �x {✓ s hereby certiry that the application for disposal works construction permit sided by the dated �'�" `�� concerrlinQ the C. property located at A y 6 Aej&,-Auo�) �r meets all of the t-k—t followinc, criteria: VThe failed system is connected to a residential dwellingonly. There are n o commercial or business <es associated with the dwellin;. • The soil is classified as CLASS [and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of he proposed septic system There are no private wells within !50 fee:of the proposed septic system There is no increase in -dew and/or=ha.nge in use proposed •There are no variances requested or needed. �Ihe bottom of the p=ecc,red leaching iaclity will not be loca ted less than five feet above the ma.-dmum adjusted groundwater table eleradon. [Adjust the goundwater table using the Frimptor rthad when applicable!. cIf the S.A.S. will be located with ? 0 fee:of any�-e;e:ated wetlands, the baaom of the proposed leac`ung facility will net be located less than -.ouneen (1-) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS jnformaLion) B) G.W. Elevation � V = the Figh G.W. adjustment D FE ENCE EET,W EN A and B DATE: [Sketch proposed plan of system on back]. ` q:health folder.Bert �® �1 Y 1