HomeMy WebLinkAbout0194 ARROWHEAD DRIVE - Health 194 Arrowhe4d Drive
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No. b"y( � �7l Fee L uy_
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rppfication for Mis osar *pstem Construction permit
Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No. T— `
cd I�Lqnhts
Arrow6>��l� t-rvi new r • uLka) , -- FAsses�o�'slGlap/Paztetl � �L�Q19 /ZG� �i
I Tel.No. SO*- 3(,,pt .IL Designer's Name,Address,and Tel.No. p9- 3?-S
.3 Y>�! OrO� !� $ti.•`aC,t ,Q�'Pil� r -s��'71 d acDl 713
Type of Building: l� a`S" y
Dwelling No.of Bedrooms Lot Size d , .ft. Garbage Grinder( /
ri
Other ' Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date neAU1 j. Number of sheets r Revision Date
Title
Size of Septic Tank Type of S.A.S. e.4 GJ�- l3
Description of Soil Ser soy) /P '
Nature of Repairs or Alterations(Answer when applicable).
Date last inspected:
t
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. c 2
Si Date O 7 [
Application Approved by Date g---Z Q/
Application Disapproved by Date
for the following reasons
Permit No. ?p 1 •— Date Issued
A ` ' ? 1 /
No. t f1 `1% Fee l UV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: A7
PUBLIC HEALTH DIVISION-- TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Tipplication for I oSaY.6pBtem• -onst action 3permit
\,.., h
Application for a Permit to Construct( } Repair ) Upgrade`( ) Abandon( ) Complete System ❑Individual Components r
VrI66 �S-7
Location Address or Lot No. / �y, Owner's Name,Address,and Tel.No. 3
7� - �4 i� ti oll /+AJ ►)nftiAsse ors ap/P el "n j
It}Iss�l"l�i¢� Q Tel.No,.y�$o�' 3 Designer's Name,Address,and Tel.No.
3 E:11l e✓ it�/ nC 07 od � 7 SL,, yyf5er ��h r h�-P//� /�G/3�y 7/3
Type of Building: ;Well
�5
Dwelling No.of Bedrooms Lot Size 3Vs'_t .ft. Garbage Grinder( /IVP
Other Type of Building /ft, No.of Persons Showers( ) Cafeteria( )
Other Fixtures ��►► _ q
Design Flow(min.required) t'7 ✓ gpd Design flow provided 45 Q--. i 9 gpd
Plan Date 77-Li I!, ,/ 5 Number of sheets Revision Date
Title -
Size of Septic Tank Type of S.A.S.
Description of Soil S -r Sc, 110,r
Nature of Repairs or Alterations(Answer when applicable)
SIf
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the.afore described on-site sewage disposal system m
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of ealth.
C
Sign `n......:` Date I - 7
ed
Application Approved by (-n Date
Application Disapproved by Date
for the following reasons y
Permit No. 'o 1 — 3 1 Date Issued if-
----------- y""
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IST O CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓) Upgraded( )
Abandoned( )by _L�`94101 /jy S., G.�I✓J
r.at W,yG rt 4hs b,Mii .Anstructed in accordance
7 _e y�
with the provisions of Title 5 and the for Disposal System Construction Permit No. (' �� d ated � .Z/.
Installer I.S 6 r0 NrS (moo�? S�. Designer S ��-�At t�� �"�,�pP P✓i� C
#bedrooms 13 Approved d flo ��, i� �/ ''gpd
The issuance of this ermi shall not be construed as a guarantee that the system ill fuhc6on as de igned.
Date o 2 Inspector 6 ,/ >
No----��aY( �.%, ': -::-.--w •.^„ --»....-_-_:,-..,r.,--Y------..._-----------•-----•-•---•---•------•----------._,Fee
-----=--L)=-_-_---
3 THE COMMONWEALTH OF MASSACHUSETTS
�6 S PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
misposal 6pstem/conBtrUctiott permit
Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( )
System located at 5 L� n D N PsG� bay
/ i
and as described in the above Application for Disposal,System Construction Permit. The applicant recognized his/her duty tb comply with
~ Title 5 and the folfowing local,pro�visions or special conditions. � V
Provided:Construction m st be/completed within three years of the date of tliis permit. - -p
Date �/ ( Approved by V�s,
Town of Barnstable
Regulatory Services
..� Thomas F.Geiler,Director,
Public,Health Division
nomas.McKean,Director
2e0 Main Street,Hyannis,MA 02601
Office: 50&862-4644 Fax: 509-79M304
Installer&Des ever Certification Form
Date:
Designer.: t •�t" } � ,'yl-etIf iastailer; 11 I is A7.
Address: 7 L 3 Address: A.3
f.I ! i�-! f S r3 '�-}�'s'r was issued a'Permit to install a
(date) (installer)
• em at F s' z c �ti:: Ili r �- based on a design-drawn-b}f
(address)
dated J9&4&a&�
(&si er
! dhat the septic�syste�m referenced-above'vas-s installed substantially according to
i d��. which may thclude minor approved changes such as lateral relocation of the
bog and/or septic twk.
i �titc-mat the septic system referenced.above was installed with major changes (i e.
IL' lateral relocation of the SAS or any ye&CAI relocation of any compone nt
�ftb�,ep&system)but in accordance with State&Local Regulations. Plan revision or
led as-'bit br designer to follow,
ti
TERENCE
n HAYES
NAP
I S TV
f .s .(Affix Designer's Stamp:Here)
1 BAIMSTABL€ PUBLIC A AI;TH DIVISION. CLRTfFICAZ`
OF . . 711I.i. f BE ISSU I} UNTIL BOTH TSIS-FORM AND AS-
W71LY C AM:�'ID BY TEE:BAWNSTABLE PUBLIC HhALTH I?IVISIOl�.
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Town of Barnstable
Regulatory Services
• Thomas F. Geiler,Director
= BAPxsrnsu.MASS -
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: /C - a(a - 1 l
Designer: July�C't'/ S';:'1'" 0E4I -�%;�Installer: /=JI I S. A-e ce74,sl
Address: ,moo X I3 Address:
S G.S was issued a permit to install a
(date) (installer)
R
tic seem at-- 1 k-l2 �) /J ( C /) based on a design drawn by {�
(address)
l h J y�� dated ,
(desig er)
4
€ oertifv that the septic system referenced above was installed substantially according to ;
the de�igL which may include minor approved changes such as lateral relocation of the
dL,--uibu&on box and/or septic tank.
-I f-that the septic system referenced above was installed with major changes (i.e.
1W lateral relocation of the SAS or any vertical relocation of any component
4h::: -fic- -stem)but in accordance with State & Local Regulations. Plan revision or
m�& as-bni_tt by designer to follow.
TERENCE\
J _
HAYES
No. 979
�~GISTO'
S-INITAR,PN,
�--� (Affix Designer's Stamp Here)
�3 BNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF ' III BE ISSU-ED UNTIL BOTH THIS FORM AND AS
X ICAM :RK�L M BY TIE BARNSTABLE PUBLIC HEALTH DIVISION.
llM*'-IY .
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Fo :.:Your;nfor lon Business eertificates:::cost:: 40: a°fon'4 arS A';buSrns"ss:cei�tif'ieate:ONLY F3EG S RSYOU;':r. E i.>town:::which< o.
at:•...... : ..... ..: .:.:.( Q.. ...., ..,Ye..:....). ...,....... . ..... l TEI T R..hAM. n......:. ( .,;.: y. u: CAI I
. :. ust f'o to:: erate You rn r� ::
mWst<do;:py:;Ma'.-sit d .es nvt:grv.e yQu Permission. ..op J st o tarn.t e.neeessarysrgnatures..on this form at 200>Marn:>St :Hyannis. r.
.Take the com pleted fdrm'td::the Town Gferk's Office;:1s 'Fl ,367 Main.St., Hyannis;:MA 02601;(Town H.A. •get the>Business Certificate that,rs
„req:a.tred l:y:law:
_
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TE:;:g-- -- - Fill,in. `(ease: '{I
.: ::... ?r _. . : .. APPIJC. . ..:. `' � (VIE s
fi ANTS' Y....OUR:<NA f�� -`K�.Pc R s•
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..YOUR HDME ADDRESS. 1 g�. A-r�l� hf� a-�..:..:��] •��'�. .....BUSINESS..:.. l�r:r:'::�:y-�t;.�::):;,.:, -
a —
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sr�
SOC I.AL 'SECURITY gR E:!N :#< O S--Z G
AME'� 0 TIQN:
N: F CR:F#P..
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C .. TYRE':OF::BUSINESS N_!2.�;G .. -.._.. ...._....�
NAMEF NEW4BlJSlNESS
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:..: f1STHIS::A::HQMEOCCUPATION:?»>::>::>;::;::;
A:. .
..DDRESS DF BUSINESS>:: >.S �.1 w� MAP PARCEL N
I U�xBEA..� i Assesin !: 'i `
WF'ba eta n . ::new;6usr ess here,a: . ever:. r 's oL UsG d[xli:;or•derzto:.baslrt!com 11 rtde:WrtftSthe tole nii<''e nfatrons:of Ede` :o
_., r .,.$ : ...,._ t`�,rS._.......t th.n9.,-:JL_.:ftl....:"... ..rt._,.:__..... _._ .: ►'eg --.4, r►._of
6arrtstoble...:�`his,;forrn:�s;;rntended':to.<ass st: bu`I`::'obta nin >Fie.:r for:.: or�a..ott :` e a''rYou N1U.ST:GO°TO"2°(],(.lain>:St;—':co" 5x
:,... ,....:,':..._ r..:..,Y... 0._.... ..1._...:9,..._:_.�1.__.;m:A>a._.u„y; ..may,ns. d.; 0 :►'ner'of.Ya_ moutf ,.
Rd; &�1lla.ln. teet:). to.,.fnakesyr@.:.yau.ha► � app�nprtEiperrrS:rtsr�d ifcenses,:�egwred:to.:legally gperate yaur>busrness m-'tjs
MUST COMPLY WITH HOME OCCUPATIOf�
1' lUR TO
1IL,!DINGsiL'DIV�M.fsSION F1�s . rFtC
-.::.. '
::.
' liln. w,rdusfh�s::be.enl �rj' Qrrri. :- :' st a ert �n;tars poffausinss.: RULES AND FAIL
` -_.P.. _ .--..t..,. COMPLY MAY RESU.I Ta'N:FINES:
. uthorirec]>Si:.`natur,;:i** _.
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Th(s.')n#rvrdualhes;:bee nfor .ed:.of::ahe: "ermit>ce urrements'::that ertarn:toa 's= a qfi>business:4 QZ �
.:i V �:: :.:.
MUST COMPLY WITH ALL :" �
Airthoatzed; iiat[ir�e>*'*
<." A7.4RQ0US.MATERIALS REGULATIONS r
QQMMENTS;:.:,::.:___s - /l c,P::':<:: - G2'�C t• Z�s�`'wJ ����"��'!'`- �' ?T' H..�
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N . 1�FF.IRS� 'TEEN 1 AU O .. -L TH. R TY
-
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.. ..i. o th s e;:of:>busines .. :. a-
.—:.v:!2:!3m...___L__.s_ ... i: .. .:::1...
xG
:.::.::,
tho .zed::Sr
a, v:::. ..:......:..:.. .... d fi
u �v>,
._... — ...... : �_i:!:':Lt:.'f�!.:!!::,:�:`:':"....—r...•�..�....�.... ...
CDMMENTS. 9 -_ a:vTT-r�i,_::_ -.�,.:�� :. .:._._....._._.... t...
�.... .... .. .... _._..._ .. .. ................... .:. .. ......— ........ . .. ....._... __ —
..... ...r.... .... .. .}. :.... ......... Q
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it
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... IN
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r.......�.x................. ... .. .. .... .... .. ... .. 'i: ii ':.:i,..: i.,,,
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TOWN OF BARNSTABLE Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORW
NAME OF BUSINESS: qpC_ S F6LV f.0 C a s
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER: �309 fit{ ,(3 g 7
CONTACT PERSON: J QSf2RnAc14_ L030 !'�?
EMERGENCY CONTACT TELEPHONE NUMBER: 3 ON 3c.Y /3 R_9 MSDS ON SITE?"
TYPE OF BUSINESS: A0L1DSc,,rP1v6
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 Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
U ,�nty.Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
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 ,Fc Fertilizers
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
WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS A plicant's Sig ature Staff's Initials
1
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.
I
DATE: - Z-2-0/(0 Fill in please:
APPLICANT'S YOUR NAME/S: R 1-0 0
Cs
• B �i�j['��k'�w hl..
' f BUSINESS YOUR HOME ADDRESS: 94 A-ie el_ 14 4N�_//
W
'Aw
as TELEPHONE # Home Telephone Number
NAME,OF•CORPORATION: F�f-b��zya�►or� S
NAME-OF NEW BUSINESS.: E�! E6�R1s Lc.t-, c CPC .9.crLUncESTYPE OF BUSINESS ArU 0 C.<za-a C
IS•THIS A HOME OCCUPATION? YES: NO
ADDRESS OF BUSINESS l>eLc.� C- 4C fir MVr�) MAP/PARCEL NUMBER �C z' `�: �(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.
1. BUILDING CO MI SIO R'S OF ICE
This indivi i al h s i f a y p mit requirements that pertain to this type of business. MUST COMPLY WITH HOME OCCUPATION
A, on d igr� y RULES AND REGULATIONS. FAILURE TO
QMMENT COMPLY MAY RESULT IN FINES.
(} c �L
2. BOARD OF HEA TH
This individual has been informed of th req ire ents that ertain to this type of business. MUST COMPLY�6 ALL
NAZARDQUS MATERIALS REGU.LATIOIS.
Authorized Signature
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 EfAWNSTABLE Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: P t✓AF-G4,1' 1 ijl(v cCAPF S 6LUf CFC
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER: S-09 3 g -7
CONTACT PERSON: J QS(!WA,0- 1-080
EMERGENCY CONTACT TELEPHONE NUMBER: 3 oX 3h Y /3 R 9 MSDS ON SITE?
TYPE OF BUSINESS: L Se-,tP1v6
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 Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
U .d GncL•Gasoline, Jet fuel,Aviation gas
Photochemicals(Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
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 ;gk Fertilizers
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
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS A plicant's Sig ature Staff's Initials
�( c)JLP��
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.
. _ DATE: - / Fill in please: `
m� `. APPLICANT'S YOUR NAME/S: .
c i qns �a .
t�q BUSINESS YOUR HOME ADDRESS: R 0 lU -�E�L2 r-1 N Id� o
TELEPHONE # Home Telephone Number
NAM E,OFCORPORATION ,
:T._.r...__k.: s ru: �i-. :{.y.".. 'h�..d�1�1� gYgrr "�+°'fr :+x�r -.+. e 5^Y!rt...w�.,:-.^#•Y_ ..'s�e .r; ,.,6..,-:.'4 � a*..5�._ Y-..a s�k xn.:� '- %.�a.t,
NAME OF NEW BUSINESS- &A 4.
rW .T,' .+'N}s -uV•. -M i-`P:-C �'� 7d'.:•". t Ya�. ".rwi _ M' iY4 v � .1- d�� txY,i 4��r
IS•THIS A HOME OCCUPA7n N?-;X---z
ADDRESS OF:,BUSINESS "- 0 " b` __� - c1�+*art .1 {' MAP/,,PARCEL NUMBER `7 -r11 - "j (Assessing]aw,4-
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 COI ISSIO ER'S OFFICE
This individl his e n infor d�pequirements that pertain to this type of busines�/IUST COMPLY WITH HOME OCCUPATION
\\ - RULES AND REGULATIONS. FAILURE TO
Au hoc i na **COMMEN"S .fnihCOMPLY MAY RESULT IN FINES.
OMMEN
2. BOARD OF ALTH
This individual has I eer�f une�J of the permit requirements that pertain to this type of business.
II YY VV �I//!! MUS7 ,OMpLY WIT!•I ALL
~ Authorized Signature** "
'tQ RDutJS MATT=RIMS RFC!4!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: J I 51
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: fO14105 EtojZ t•1 ().-,t
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: Ig g A-gR.0I,U tj6&0i" pc TOTAL AMOUNT:
TELEPHONE NUMBER: 50,g 9611 / ? A�
CONTACT PERSON: &S Logo
EMERGENCY CONTACT TELEPHONE NUMBER: $�0-8 364e1 MSDS ON SITE?
TYPE OF BUSINESS: i
INFORMATION/RECOM MEN DAT NS: 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 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)
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
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,
i 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/CANARY COPY-BUSINESS Applicant's Signature Staff's Initial
TOWN OF BARNSTABLE •
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT -�
INSTALLER'S NAME & PHONE NO. �nSP-1, �
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) `pG �f ) (size)
NO. OF BEDROOMS PRIVATE WELL ORX—& UBLIC WATER
n.
BUILDER O OWNER�j � �e
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diti-poottl Morlui Tomitrnrtion Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair (L54 an Individual Sewage Disposal
System at:
.... •...... ................... .................... ---------------------------------------------•-
Loc ion.Address or Lot No.
......................l�.�.....-•---•/.Y.Y.-•------- v��•�e- � .�JIL��J �s�J�l1.S
Owner 1 Address
9Q Installer 4 Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
NOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04
Q Other fixtures ........................................................................................ .............................................................
W Design Flow.................. �_........____gallons per person per day. Total daily flow._._........�..s?..a_...._......_...__gallons.
WSeptic Tank—Liquid capacity.1�0__gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. ....................I Width.................... i_._._....... Total Length................... Total leaching area....................sq. ft.
3 Seepage Pit No----------- _._._.__ Diameter........�0_..... Depth below nlet......4.J.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by.......................................................................... Date........................................
W
,a Test Pit No. I................minutes per inch Depth of Test Pit--------------------- Depth to ground water........................
L74 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ........................................................••-•--...........•-------------••-•••---.....-------••--••._........._----•-.........................
ODescription of Soil........................................................................................................................................................................
V .............................................-...........................................................................................................................................................
W
-------------------------------------------------------------------• ------------------•-•-------•--------------------•-------.....--------••--------------•-------------••-
U Nature of Repairs or Alterations—Answer when applicable. _..I.h1.cTIr- ._�'._._./U0D '94...S°t�T7-�._-.
- ---------
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has en 'ssu b he andtoffhheaalltth..
z: ��
Signed ...................... . ....... .....:.... ..
Da �tj
n / ce
Application Approved By ............... .... � .. — ....!. .............................................................. .........��Due
r;)..-`�--y
Application Disapproved for the ollowing reasons., ........................................................................................................................................
........................................................qq........................................................................... ..........._............ .............................................. .--....................................
PermitNo. .............`..L...... .................. Issued ........................................................ ......
Dare
7b ivy
Fick .3a... ......
THE•,COMMONWEALTH OF MASSACHUSETTS t
BOARD OF HEALTH
`ter TOWN OF BARNSTABLE
Appliratiun for Dhripuuttl Wurk.5 Tunutrnrtiun rumit
Application is hereby made for a Permit to Construct ( ) or Repair (p4 an Individual Sewage Disposal
System at:
--�-,F............................... ................•-------•------------ -..... . . ... ,.......'----•------•-•-----•-•- ---- -..-..---•--•-----•----............ ..
�GdS�/Ly j e�Sio'c-Address/J�C1ivJ �-- �/ _°J /1 !�or Lot %N1.1
............................
Owner j Address
-7 c (_S----------------------f------------------------•. Y •------......................................
Installer /Address Type of Building Size Lot............................Sq. feet
.� Dwelling— No. of Bedrooms............ .......................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ------------------------------------- -
W Design Flow................... .............gallons per person per day. Total daily flow.___._.--___3..5?a....._..........__gallons.
WSeptic Tank—Liquid capacity.� ?a__.gallons Length________________ Width__........__.___ Diameter... ............ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
• 3 Seepage Pit No-----------/........ Diameter--------!�U...... Depth below inlet.....6........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
Test Pit No. 1................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........................
p' ...........................................................•--•--...----------•••-----------.............-----------------•................-.................
0 Description of Soil................::....:.:.:
x
W
UNature of Repairs or Alterations=Answer when applicable_.__.1..!.1� i�!.! __._ _.__/UD U_G_c -_s �77-c;_._..
(s1:til t ..=.• 1,!�S = ... �` ;--------- l��0 5` ............_.!.. ------ `............................... -..:.............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been 'ssue by he board of health.
f
Signed ..................`../...... ..:..-. .-.�J Gi ........ ......., //.............. Dace
Application Approved By .................. -. ......�....
.................................................
Application Disapproved for the following reasons: ........................................................................................................................................
-u
R
Due
Permit . ................. . ...../ .o ?.................. Issued ...-....... .........................................No ......
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
IVITWErtifirate of (11pomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
b .............................................................. -.1a1. .... l.t�1. ..t../.... ..c•l �.1...:.............................................................
y
ms�aue�
at .......... .....................................1.�7 a,1�......... ...... ...... ................ `'1tVn1.? ..........................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .. -=.-_ ............. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR ED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......L....l...`........... ./......^...... ............................ Inspector ...........`... l if�s2� .............0 ..................�
--—— -------------------------- -------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -70 D �y
TOWN OF BARNSTABLE
FEE.---::�U..
3�iuuuttl Turku �unutrrtiunprmit
a�C-z�.crc, i �!-`'`� ........ ... ..................................
Permission is hereby granted......................�e.....
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No. l✓� cl /I-�2/L w r = ��21 v. :-- ",�l�a -"�11.................
Street
as shown on the application for Disposal Works Construction Permit No---7,L,,�_�. Dated........ `.-L!.....
1 ----------------
DATE...--•--------- .................................. Ob
oard of Health
FORM 36508 HOBBS&WARREN.INC..PUBUSHERS
cn� c SOIL TEST
TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLAR OR CRAWL SPACE DATE OF SOIL TEST Y 1 �0?1
ELEV. 100.00 10 FT. MINIMUM 10 FT. MINIMUM FROM SLAB SOIL TEST DONE BY SY CLEAN SAND ENGINE RING
(ASSUMED)
CONCRETE INSPECTION PORT WITNESSED BY D. DF., P#21280 AIS .___._____
COVERS
4" SCHEDULE 40 PVC PIPE LOAM AND SEED 2" LAYER OF OBSERVATIONHOLE 1 ELEV.=_ 98.5
MIN. PITCH i/8' PER FT. 1/8" TO 1/2" PERCOLATION RATE <_ MIN./INCH AT - 58 -_ INCHES
WASHED STONE
99.2 MAX. OR FILTER FABRIC VENT DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
3.00 4" CAST IRON PIPE " " 97.0 MIN. NOT REQUIRED 0-9" Ap _ LOAMY SAND t0YR5/1 NO ROOTS
(OR EQUAL) MINIMUM
PITCH 1/4" PER FT. LEFL RS TEE 9-32" 8 LOAMY SAND 10YR6/4 _- ROOTS - -
32-126" IC MED./COAR. SAND 2.5Y7/4 PDX COBBLES
FLOW LINE °'
NO WATER ENCOUNTERED AT 126_ ELEV. _ 88.0
ELEV. _ _Q7�QQ_ MIN. 2 ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑ ❑ ❑ y
LEV. _ _�• _ LEVOEI o00 00000000000
o ° OBSERVATION HOLE 2 ELEV.= 98.5
° ° o
ELEV. _ _ _ ADD GAS ELEV. _ _31' 7_ 6" SUMP ELEV. _ _ �_ o °
00000000000 0 2� ° DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
BAFFLE DISTRIBUTION o o ° 0-8" Ap LOAMY SAND 10YR5/1 NO ROOTS
LIQUID OUTLET ELEV. _ ° °°° ❑ ❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ° ° �
0 0 o ° ° ° ELEV. 8-33" 8 LOAMY SAND 10YR6/4 ROOTS
BOX -�_ _ ------
4 FEET 14 INCHES (EDEPTH TEEXISTING) TO BE WATER TESTED 2 500 GALLON GALLEYS WITH 33-126" C MED./COAR. SAND 2.5Y7/4 10X COemS
5 FEET 19 INCHES IF MORE THAN ONE OUTLET STONE IN AN _
b FEET 24 INCHES 1000 GALLON NO WATER ENCOUNTERED AT __126_ ELEV. _ _ s8.0
7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE) 13� X ?b' X Z• TRENCH FORMATION z WELL NIA
/ llTlt -
8 FEET 34 INCHES SEPTIC TANK � �� ZONE
3/4" TO 1 1/2" CLEAN SOIL ABSORPTION Ln INDEX DESIGN CALCULATIONS
DOUBLE WASHED STONE �/�► ADJUST NUMBER OF BEDROOMS 3
FREE OF FINES do SILT S 1 .ITEM SAS GARBAGE DISPOSAL UNIT
USGS PROBABLE WATER TABLE ELEV. TOTAL ESTIMATED FLOW
SEWAGE DISPOSAL SYSTEM PRORLE OBSERVED WATER TABLE ( / / ) ELEV. _ _ ( 110 GAL/ LAAY X ,r3._ 8R.) GAL./DAY
NOT TO SCALE BOTTOM OF TEST HOLE ELEV. _ _d1.Q_ REQUIRED SEPTIC TANK CAPACITY = GAL.
ACTUAL SIZE OF SEPTIC TANK (E)IMM) i9W GAL.
SOIL CLASSIFICATION
DESIGN PERCOLATION RATE 5.�_ MIN./IN.
EFFLUENT LOADING RATE GAL./DAY/S.F.
LEACHING AREA SO. FT.
(13J=)+(38I=)
LEACHING CAPACITY (AREA X RATE) sue'2M GAL/DAY
477.00 X 0.74
RESERVE LEACHING CAPACITY _NQW_ GAL./DAY
NOTES:
1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P.
TITLE 5 AND THE TOWN'S RULES AND REGULATIONS FOR
THE SUBSURFACE DISPOSAL OF SEWAGE.
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
WITHIN 6" OF FINISHED GRADE.
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN
10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS.
4. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL
BE MORTARED IN PLACE.
5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
���IMtUC e:='-€'oe +,.. ,r uatt- r ra.:.. K;
;� :F.��..-s..�1�«.,1�'-a.:s. �hi'�G.1'e-' r �ii�Ll +Mt
O€3TAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
6. UTILITIES SHOMV ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR
of r4q IS TO CALL "DIG-SAFE" AT 1-888-34-4-7233 AT LEAST 72 HOURS
PRIOR TO COMMENCING WORK ON SITE.
7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS
SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. ANY VARIATION
IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER AY
Q IMMEDIATELY.
�0 8. PARCEL IS IN FLOOD ZONE X
99.3 STE�`�, 9. LOT IS SHOWN ON ASSESSORS MAP _ AS PARCEL - 84
�1 LOT 24 10. EXISTING PIT IS TO BE PUMPED AND REMOVED ALONG WITH ANY^
9,345.4 t S.F. SOIL IF POLLUTED SOILS ENCOUNTERED.
11. THE INSTALLER IS TO GIVE THE ENGINEER A MINIMUM OF 48 HOURS
2 99.5? � 13'0, ��TEST 1 � - (2 WORKING DAYS) NOTICE FOR THE FINAL INSPECTION (NUMBER BELOW).
. 98.5 C
i 1000 GALLON SOIL
/ SEPTIC TANK - t
TEST 2 RO '
Oa '~ WD.
► 1
1
99.3 BOX � �N 98.6 ci. ' �•�.1 w�
APPROVED: BOARD OF HEALTH
41
'1 99.2 I .0 98.5
�l _'``-99. 99.5 PIT h
.9 DRIB 99.0 7 j 99.0 ^ DATE AGENT
99.2
99.2 " 9 ., PROPOSED SEPTIC DESIGN
(>•oo) HYANfNis,
MASS. FOR
_J
ANDREW FALTU{NER
25
194 ARROWHEAD DR. LOT 24
W HYA►NNIS, MASS.
Z In t S
a 203 SETUCKET ROAD
o w P. 0. BOX 713
LEGEND: z 385-6900 SOUTH DENNIS, MASS. 02660
cr
EXISTING SPOT ELEVATION 00„0 x
EXISTING CONTOUR ----00---- Q DATE JULY 19, 2021 SCALE 1 " _ 20'
FINAL SPOT ELEVATION T
FINAL CONTOUR UTILITY -O-
L TE POLE LOCATIONLOCUS
U REV. FJO-11NO, o -
TOWN WATER -W�---- W
CATCH BASIN
GAS LINE
CLEAN OUT c. . LOCATION MAP REV. - SHEET 1 OF i
�CESSPOOL C.P. 0
! �_ C +S$ PRo✓ 651PS- 00 dw f}3$5-SAaDNG 0 2021 SWEETSER ENGINEERING
TOWN OF BARNSTABG�LE
LOCATION 1-4 �! 'SEWAGE# C ;�/ �/
VILLAGE / ASSESSOR'S MAP&/PARCEL 7y -ukL/
INSTALLER'S NAME&PHONE NO.O.=//I'S J
SEPTIC TANK CAPACITY /0 0 U
LEACHING FACILITY. (type),J- jdo C 00M s (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE: IOAVnzi
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
I
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