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0274 BARNSTABLE ROAD - Health
T274 Ba'rnstaW'Road-NO R'Sewer Acct # 4294 H ann. ' Y�,, , J1JSl17tin�' � I A = 310-436-002 13 ,1 ' q Y j / /4 l' C FF Af E�Date: �-3 / I 1 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: ('rv� A+ rylo" BUSINESS LOCATION: 9q It low {Q INVENTORY MAILING ADDRESS: SLme, TOTAL AMOUNT: TELEPHONE NUMBER: goy- 'ill CONTACT PERSON: S,,K, ONE_, EMERGENCY CONTACT TELEPHONE NUMBER: 24$-Le3 --L32_g MSDS ON SITE? TYPE OF BUSINESS: 'Dtvn (� INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: V/`Ffb'bCL Last shipment of hazardous waste: t -4 Name of Hauler: -Sftg.waF Destination: ty-44- U?-� Waste Product:>4s, 64A%At- 6 Licensed 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 A NEW 1A USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW — USED Degreasers for engines and metal Nnting 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 waxesand•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, 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 a`removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant' gnature Staff's Initials f. TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH O 3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANY �,Hdc�Q.�S�� (see"Orders") 5.Retail Stores . 6.Fuel Suppliers ADDRESS Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALSUnderground IN OUT IN OUTI IN OUT #&gallons Age Test Fuels: Gasoline Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: � 9 ➢� DISPOSALIRECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply Sb n7,,rlzco A,S'Ds Town Sewer Public O On-site OPrivate 3. Indoor Floor Drains YES NO x 0 Holding tank:MDC 0 Catch basin/Dry well 0 On-site system . 4. Outdoor Surface drains:YES NO ORDERS: 0 Holding tank:MDC O Catch basin/Dry well (Alon-site system 5. Waste Transporter Name of Hauler Destination Waste Product YES NO 2. Person(s) Interviewed Ins ctor D to Date: U TOXIC-AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: (dnf/ Ohl BUSINESS LOCATION: - , lf_� MAILINGADDRESS: Mail To: TELEPHONE NUMBER: 0? Board of Health Town of Barnstable CONTACT PERSON: P.O. Box 534 EMERGENCY CONTACT TELE HONE UMBER: Hyannis, MA 02601 TYPEOFBUSINESS: n(,_ Does your firm store a of the toxic or hazardous materials listed below, either for sale or for you own use? YES V NO This form must be returned to the Board of Health regardless of ayes or no answer. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: /I J ADDRESS: TELEPHONE:. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze'(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel / Photochemicals Fixers) Diesel fuel, kerosene, #2 heating oil NEW ✓ USED Other petroleum products: grease, Photochemicals Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Form Approwd:OMB No.0910-021 S. FOR FDA USE ONLY DEPARTMENT OF HEALTH AND HUMAN SERVICES E)pIradonDaY:D•o•mb•r31,1997 Public He�I1Service s••R•wrs.broMeearm•ne FOOD AND DRUG ADMINISTRATION REPORT OF ASSEMBLY3 5 7 6. OF A DIAGNOSTIC X-RAY SYSTEM 1. EQUIPMENT LOCATION 2. ASSEMBLER INFORMATION a.N OFHO PRAL,DOCTOryryOROFFICE WHERE N�STALLED •.COMPANY NAME 0 b.BTRE AD RE b.STREET ADDRESe ��� �,�S "3ATTEEi60N DENTAL COMPANY 42 CUMMINGS PARK a CRY d.5 ATE a CRY W08UHN, MA 01tJU1 I d.STATE r1'Y�vA 15 •.ZP,FODE 0I . 5u.a� L TE��pJWNE�IIJMB�� '/^Q� o.IpCODE - -1. TELrcPHQNEHUMB3�-� 3. GENERAL INFORMATION _��l/l�s�[J aJ1 ,lU� 1 '"(f •.'THIS REPORT IS FOR ASSEMBLY OF CERTIFIED COMPONENTS WHICH ARE(Chedrepproprlats box(*&)) NEW A98EMBLY-FULLY CERTIFIED SYSTEM REASSEMBLY-FULLYCERTFED SYSTEM ❑ REPLACEMENT COMPONENTS N AN EXISTING SYSTEM ❑ REASSEMBLY-MIXED SYSTEM(Doti oerededendna a rUd dcomponents) ' ❑ •AN ADDITION TO AN EXISTING SYSTEM b.NTENDEDUSE(S)(Checkepproprlale(bo4ee)) ❑ PODIATRY ❑ CTHEADSCANNER DENTALPANORAMIC ❑ GENERAL PURPOSE RADIOGRAPHY. ❑ UROLOGY ❑ CT WHOLE BODY SCANNER ❑ RADIATION THERAPY SIMULATOR ❑ GENERAL PURPOSE FLUOROSCOPY ❑' MAMMOGRAPHY . ❑ HEAD-NECK(AMdbl) ❑ C-ARMFLUOR0600PX) ❑ TOMOGRAPHY(Ofur Man CT) ❑ CHEST ❑ DENTAL-NTRAORAL ❑ DIGITAL ❑ ANGIOGRAPHY ❑ CHIROPRACTIC .❑ DENTAL-CEPHALOMETRr, ❑ OTHER(SpedyIncomments) a THE X-RAY SYSTEM S(Cheokorw) d.THE MASTER CONTROL'19 N ROOM '*.*DATE OF ASSEMBLY EL STATIONARY I 01 ❑ MOBILE (Mo.) (day) (A) 4. COMPONENT INFORMATION(If addltlonal space Is needed for this.section use another form;replacing the preprinted number with this Form Number,and complete Items 1,4,and 5 only) a.THE MASTER CONTROL 19 b. CJ D � � ���i.rC VT i u d� SERIAL 3 /E � •.DATE MANUFACTURED G ��[J ❑ A NEW NSTALLATgN EXISTNG(Cofftd) a yM�O/D�EL(NUMBER IL I. SYSTEM MODEL NAME(Crs amsoy) ❑ EXSTNG(NonoMMd) i L,IC-_\ ( . Compl�ethefdlowirTInformationforthecertlfled components llatedbelowwhlchyqultkstallqd..EQ.rbeamlirplt-IngcJg(jc@s,J�Wes.agdCT pMLesent�erltiamanufecturer_and--___` XXi7Faimlier fn ttie`Indfceded spaces.Forother ceR(fi-ea&Wppdnents,enter In the appropriate.blodce how many of each you Installed In this system.. 9. S9LECT8D OOMPM9NT8"-n%,,:..:..: 1. CrHER,CERTFXD COMPONENT8 A. . . (EnYrqumMro/each hetslNdM apprepAeb�draJ " . . MODEL NUMBER r �,: DATEQ@ ,NUFACT�,URED7ACTURER �ls _�I�: C. '` 1 •'� ,❑,'X-RAY CONTROL ,.N ❑ CRADLE M FACTURER MODELNUMBER •/ry/ ']�/-{'(, DATE NUFAfTR1REvpD�. .. "- """•1C.' r`.✓O• I'`/ I`� . ' �1 "( - `❑,';HOHVOL7AGEGENERATOR. ElFLMCHANGER MANUFACTURER' MODELNUMBER .DATE MANUFACTURED - ❑ VERTICAL CASSETTE HOLDER - ❑ IMAGE NTENSFER MANUFACTURER MODELNUMBER' 'DATE MANUFACTURED ❑ TUBE HOUSNG ASSEMBLY ❑ SPOTFLMDEVICE MANUFACTURER MODELNUMBER DATE MANUFACTURED G E$ DENTAL TUBE HEAD ❑ OTHER(Spedy) 5. ASSEMBLER CERTIFICATION T _affirm that all_cerlified component assembled or installed by me, for which this-report is being made, were adjusted and tested by.me according to the instructions proOded-by the r6ihufacture(s;were of'tWtype req by%uired' the,tnarwfectvrer(s),=were''of the,type'require�Y'by the-dagnostiox-ray performance standard-(21-0FR Part 1020),were riot modified to adversely effect performance,and were Installed In accordance with provl: o>}21 CFR Part 102D. I also affirm that all instruction manuals and other information required by 21 CFR Part 1020 for this assembly have boon-furnished to the purchaser and, Within 15 days from the date of assembly, each copy of this report will be distributed as Indicated at the bottom of each copy. a.Pro NAME b.BgNA a DATE e Or Art 6. COMMENTS --PaS FORM FDA 2V9(6195).PREvIousEDITIONISOBSOLETE U.S.GPO:1995-39946B2034s EF Pink Copy-Purchaser Badew r voice vv4.� ' MICHAEL P. SEIPMA-N, D.D.S., P.C. General Dentistry DENTAL ASSOCIATES OF CAPE COD 262 Barnstable Road Hyannis, Massachusetts 02601 -- - 508-778-1200 TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops �/� p unsatisfactory- 4.Manufacturers Dw4<4 h PS'iSL��,�-f (see"Orders") 5.Retail Stores COMPANY 6.Fuel Suppliers ADDRESS a6-2 LedL Class: 7.Miscellaneous Z �S QUANTITIES AND STORAGE (IN=indoors;OUT-outdoors) MAJOR MATERIALS Case lots Drums Abo.ve Tanks Underip-ound Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel(A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic s Synthetic Organics: degreasers Miscellaneous: g. L �v 3 u DISPOSAURECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply O Town Sewer �Wublic !wn-site OPrivate / r ` � 3. Indoor Floor Drains . YES NO O Holding tank:MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YESXNO ORDERS: O Holding tank:MDC ® 1- atch basin/Dry well WkJ4e 6On-site system /1 t Co&i_ 5. Waste Transporter (� 1, Destination Waste Product YES NO 2. tUt SLDb llv� % (. Awl'17 / 4/1 �— —�� erson (s) Interviewed Inspector Date | - - ~ | ' | ' September 22, 1990 Michael J . Block , D.D.S. Cape Cod Mall-Route 132 Hyannis, MA 02601 ' NOTICE TO ABATE VIOLATIONS OF 310 CMR 30.278 Dear Dr. Block : On Friday, September 7, 1990, Donna Miorandi , Health Inspector for the Town of Barnstable, performed an on-site inspection at property leased by you d/b/a OMNIDENTIX located at the Cape Cod Mall . . The inspection was performed due to a complaint regarding illegal disposal of syringes, gauzes and gloves. At that ' time there appeared to be no problem regarding the above ' matter. The pathological waste is picked up and transported by BFI and the manifests for such are on site. However, there is a problem with your x-ray equipment. While on site it was noted that the effluent of your x-ray � equipment discharges directly to the Town of Barnstable Sewer Treatment Plant. This is a violation of the Town' s / Article XXXIX : Control of Toxic and Hazardous Materials as � well as Massachusetts Hazardous Waste Regulations 310 CMR 30.278. You are directed to have your effluent tested and to have it properly disposed of by recycling it or utilizing a licensed hazardous waste hauler or a Department of Environmental Protection approved precious metal transporter. You are directed to correct the above violation within fifteen ( 15) working days of receipt of this order. ' Please be advised that failure to comply with an order | could result in a fine of up to $1000.00 per day Enclosed is some information on testing laboratories and companies that sell recovery equipment and perform precious | metal transporting . . PER ORDER OF THE BOARD OF HEALTH . Thomas A. McKean Direqtor of Public Health cc : John Quinn , Water Quality Control - | � U 4(L N spa 13 c . �( • ` BOUSFIELD SANITARY SERVICE 451 ROUTE 6A P.O. 13OX 438 EAST SANDWICH, MASSACII0SET7'S 02537 609 888-2010 SUBSURFACE SENAGE. vI$POBAL SYSTEM INSPECTION FORM Address of property ��� NSTAI*C RD j�yAN )S Owner ' s name ROq r,C. Date of 1nspectior) '7.-1,3 PART A CHECKLIST Chec)c if the following )lave been done: humping information was requested of the owner, occupant, arid Board of Health . None of the system components have been pumped for at least ttwo weeks and the system has been receiving normal flow introduced into the period. Large volumes of water have not been system recently or as part" of" this inspection. As built plans have been obtained and examined. Note if they are not A available with NIA. X The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank ,manholes.;,were uncovered, . opened, and the interior of the septic tank was inspected for condition ,of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS 'on the site has been determined based on existing information or approximated by non-intrusive 'methods. The facility owner "•(and occupants, if- different from owner) were provided, with inforination, on 'the .,proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential _ number of bedrooms . number of current residents garbage grinder, yes or, no laundry connected to system, yes or no seasonal use, yes or no If nonresidential , calculated flow: PER onr Water meter readings, if available: - 1500 _ Last date of occupancy GENERAL INFORMATION Pumping records and source.:. of, information: System pumped as part of inspection, . yes or no if yes; volume pumped Reason for pumping: T a of system ^� Septic tank/d r- 4a&x/soil absorption system Single cesspool overflow cesspool . •, Privy . Shared ..system (yesi-or. (if yes, ,.attach previous inspection records, if any) other (explain) Approximate age of all components. Date installed, if known. Source of information: eorS Ao Sewage odors detected when arriving at the site, yes or no I 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �. PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: r��tF2S(^tle' .SU2FE material of construction: concrete metal FRP other(explain) dimensions: c -3 rsludge depth 'r distance from top of sludge to bottom of outlet tee or baffle 3 scum thickness distance from top of scum to top o•f.,outlet tee or baffle 9V distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for, repairs, etc. ) DISTRIBUTION BOX:_ (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal,' evidence'of solids carryover, evidence of leakage into or out of box, recommendation for repairs," etc.) PUMP CHAMBER:_ (locate on .site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM ,I/NFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : V f` (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leachingr pits and number 40'1 4499ax 1206 SAS, leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of pondirig, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level *of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ! 11. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or be nchmarks i locate all wells within 100 ' 1 � DEPTH TO GROUNDWATER depth to groundwater- method of determination or approximation: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? I Liquid depth in cesspool <6" below invert or available volume< 1/2 c flow? i Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: Al below the high groundwater elevation? within 50 feet of a surface water? within . 100 feet of a surface water supply pp y or tributary to a surface water supply? Xwithin a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? /v within 50 feet of a . private water . supply. supply well . less than 100 feet but greater than 50 feet from a private water ter supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water ,analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector %Cl7 Company Name ®�S F(4�,4®S Company Address - Certification Statement I certify that I have personally inspected the sewage disposal system at this -address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are . consistent with my training .and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: 6/ I have not found any information which indicates that the system fails to adequately protect public health or the environment as. defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as . stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. / Inspector' s Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority No.Z�v Fee THE CCiMMON.WEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Miqpo2;a1 *pqtem Con.5truction Permit Application for a Permit to Construct Repair Upgrade Abandon(V11ZO Complete System 0 Individual Components Location Address or Lot No.X?L/ Owner's Name,Ad ss Assessor's Map/Parcel Installer's Name,Addres"TO UNCO Designer's Name,Address and Tel.No. 350 Main Street i�rrnol.lth, MA 62673 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 -----Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 9'fQe_E n rl e!C I 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 by this Boaf d X, He Signed Vib I r�,, 'te" A 4=!6-6 4 Date o Application Approved by Date &qLo Application Disapproved for the following reasod Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS CERTlF`Y, at the On-site Sewage Disposal System Constructed Repaired Upgraded Abandoned( ��by ckco at 2- 7 Y 1U.,e-h J,6404 ao,/S4'*0 has been constructed i d ce j�/_ r an with the provisions of Title 5 and the for Disposal System Construction Permit No.'?,"/—_r�/ X dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system 'Will function as designed. Date �Inspector k No. r • I Fee 731 - r' � - Entered in computer: _ THE CC"IIIMpyVEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE. MASSACHUSETTS Yes r. 01pprication for Mi�poa[ *pgtem Con!5truction Permit .+K Application for a Permit to Construct( )Repair( )Upgrade( )Abandon(t1J/Complete System El Individual Components Location Address or Lot No..) ce r i S 4/4 h IL Owner's Name,Adqress artd,Tel.No. Assessor.ts Map/Parcel v C ' 1 1 y - Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. xi r. 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. i Plan Date Number of sheets Revision Date - Title . ` Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) V ti°I,JP r �CJ 1 /1 P i o n 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 by this Bo d He h. c� Signed 1 Date G / G ( Application Approved by Date MILO Application Disapproved for the following r;asorfs Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 4 . Certificate of Compliance THIS�-I�S CERTIFY; at the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) y Abandoned( ✓l oy rt C at 7H J ��F has been constructed i accordance with the provisions of Title 5 and the for Disposal System onstruction Permit No.O'er/—T4/T dated Installer Designer _ The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogai *pgtem Con.5truction Permit Permission is hereby granted to Cons ct( )Re air( )Upgrade )Abandon( V System located at o�7�� ,C>r��✓!f A h _%� h4y 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 b completed within three years of the date of thi 't. Date: / 0 Approved by t Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: �.�` 1_=CLL ' aeajr` k BUSINESS LOCATION: . (,A P.Sw-.a MAILINGADDRESS: Mail To: TELEPHONE NUMBER: 5 eD S 771 —D S OO Board of Health CONTACT PERSON: 5j S-+wJ TPP Town of Barnstable P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: y�3 -544-4 Q l Ql Hyannis, MA 02601 �TYPEOFBUSINESS: J S . Does your firm store anypf the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity n� Antif reeze(for gasoline or coolant systems) N Drain cleaners NEW USED Cesspool cleaners Al Automatic transmission fluid Disinfectants Engine and radiator flushes _ Road Salt (Halite) �1P Hydraulic fluid (including brake fluid) A.Z _ Refrigerants Motor oils _ / Pesticides NEW USED (insecticides, herbicides, rodenticides) A/ Gasoline, Jet Fuel Photochemical (Fixers) /J Diesel fuel, kerosene, #2 heating oil NEW USED ►'�- Other petroleum products: grease, _ otochemicals (Developer) rica , gear oil 4infing NEW / USED AJO Degreasers for engines and metal ink Al 19 Degreasers for driveways & garages Wood preservatives (creosote) Al0 Battery acid (electrolyte) Swimming pool chlorine _ ffi-�6 Rustproofers µ/ Lye or caustic soda Car wash detergents Jewelry cleaners I)_ Car waxes and polishes 1-0000 Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes /✓ PCB's Lacquer thinners Ad, Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) _ Paint & varnish removers, deglossers Paint brush cleaners 'e Any other products with "poison" labels (including chloroform, formaldehyde, _AZ Floor & furniture strippers hydrochloric acid, other acids) /J Metal polishes ��. Laundry soil & stain removers . Other products not listed which you feel (including leach I may be toxic or hazardous (please list): Spot removers & cleaning fluids AA (dry cleaners) L ,1 16 LS Other cleaning solvents N° Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: i TOXIC AND HAZARDOUS-MATERIALS REGISTRATION FORM NAMEOFBUSINESS: or- � r` f,5.4-- 4e ;+A, BUSINESS LOCATION: =) ({, �����i.�S��+-`��� 1• MAILING ADDRESS: Mail To: TELEPHONE NUMBER: S c� �, 7 91 -6 500 Board of Health 1 v A t � v Town of Barnstable CONTACT PERSON: • . S S P� P.O. Box 534 .-:,EMERGENCY CONTACT TELEPHONE NUMBER: ( 127 Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES I � NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity A) An tifreeze(forgasoline or coolant systems) '�' Drain cleaners { NEW USED ''"f Cesspool cleaners. E/ Automatic transmission fluid `� Disinfectants k" Engine and radiator flushes Road Salt (Halite) U Hydraulic fluid (including brake fluid) Refrigerants Motor oils f Pesticides NEW USED + (insecticides, herbicides, rodenticides) dt,) Gasoline, Jet Fuel �J Photochemicals (Fixers) A-) Diesel fuel, kerosene, #2 heating oil r NEW / USED i �W Otherpetroleum products: grease, F�hotochemicals (Developer) lubrica s gear oil , r NEW V USED Degreasers for engines and metal Printing ink 1f Degreasers for driveways & garages ' Wood preservatives (creosote) pjo Battery acid (electrolyte) Swimming pool chlorine _b Rustproofers Lye or caustic soda J Car wash detergents !✓ Jewelry cleaners Car waxes and polishes �^'` Leather dyes j —kfl Asphalt & roofing tar Fertilizers Paints', varnishes, stains, dyes PCB's Lacquer thinners ,4s Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers a Any other products with poison„ labels Paint brush cleaners (including chloroform, formaldehyde, .t Floor & furniture strippers r f✓ hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including leach may be toxic or hazardous (please list): Spot removers & cleaning fluids 1 ') --1 r (dry cleaners) Other cleaning solvents <''° Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS 1 Barnstable Family Dental Groin A Multi-specialty Group Practice CDPMA 276 Banuta6[e Road Linda A. O'Rour(�, Hyannis,MA 02601 Operations Manager _ (508) 775-1883 Fax 775-5607 Osorio&Watkin,DIAD,PC Date: 1 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OFBUSINESS: �,=�QIIu Ql 1"Ol)p BUSINESS LOCATION.:_ &[ru4kab MAILING ADDRESS:���' S - 1-1-C ( �-,�1 S (� Mail To: - Board of Health TELEPHONE NUMBER: Town of Barnstable CONTACTPERSON: i tom. P.O. Box 534 EMERGENCY CONTA T TELEPHONE NUMBER: =- 3 ;9- Hyannis, MA 02601 TYPEOFBUSINESS: 4 GL�A�i Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES - ✓ NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS, Quantity Quantity ;UO Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Q� Engine and radiator flushes DIES Road Salt (Halite) 6-1 13S &0 Hydraulic fluid (including brake fluid) /UO Refrigerants &0 Motor oils AO Pesticides NEW USED (insecticides, herbicides, rodenticides) &0 Gasoline, Jet Fuel Z Photochemicals (Fixers) AZO Diesel fuel, kerosene, #2 heating oil � NEW Ya5 USED _ 0 Other petroleum products: grease, � �}� Photochemicals (Developer) lubrica , gear oil y� NEW 1AO USED Degreasers for engines and metal bt) Printing ink 0 Degreasers for driveways & garages A-Z)— Wood preservatives (creosote) O Battery acid (electrolyte) AX Swimming pool chlorine Rustproofers A)O Lye or caustic soda /lib Car wash detergents A10 Jewelry cleaners ,did Car waxes and polishes kO Leather dyes l� Asphalt & roofing tar Fertilizers _4 Paints, varnishes, stains, dyes PCB's lizo Lacquer thinners �(� Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) 1% Paint & varnish removers, deglossers �S Any other products with "poison" labels ,4_10 Paint brush cleaners �( (including chloroform, formaldehyde, _AA) Floor & furniture strippers U hydrochloric acid, other acids) Metal polishes i� Laundry soil & stain removers Other products not listed which you feel (including bleach may be toxic or hazardous (please list): Spot removers & cleaning fluids a) 01 �rv�. PIL.uc.eXC. Lf (dry cleaners) ���� �j i � f►� rh r,�� Ce - Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS l ! A ` Date: 7 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: OFT\m FeJrPLAiub 1:F4.1 ►L BUSINESS LOCATION: 27( MAILINGADDRESS: �Arf,,L. Mail To: Board of Health TELEPHONE NUMBER: Town of Barnstable CONTACT PERSON: P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: C-FtC-r-_: Does your firm store an of the toxic or hazardous materials listed below, either for sale or for you own use? YES _-� NO a This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: tj V ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS:. The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid(including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuels Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil Y,NEW:'__,Y USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil _�C NEW Y- USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS �EP-06-97 17 : 46 FROM: ID: PACE ie/24 Date: (a R TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: w r6^-J `/� BUSINESSLOCATION: 2�'6 ^S $ 0 "LING ADDRESS: Mail To: of Health TELEPHONENUMBER:- s- �- Towndof Barnstable CONTACTPERSON: L-1- r P.O. Box$34 r i 1 OTC EMERGENCY CONTACT E!_EPIH�NE N/�MHER: Hyannis,MA 02601 l� C TYPE OF BUSINESS: ni c-X1 Does your firm store any of the toxic or hazardous materials listed below,either for sale or for you wn uses YES J.Z— NO This form must be returned to the Board of Heahh regardless of a yes or no answer.Use the enclosed envelope for your convenience. n / t',you answered YES above,please indicate if the materials are stored at a site other lkan your mailing ate'( S 4 f e a- address: ar ADDRESS: TELEPHONE: _ LIST OF TOXIC AND HAZARDOUS MATERIALS 1 The Board of Health has determined that the following products exhibit toxic or haial'daus character- istics and In List be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE:UST IN TOTAL UOUID VOLUME OR POUNDS. Quantity OUaniity (, ✓(✓ d Antifreeze(for gasoline or coolant systems) Drain cleaners j NEW USED Cesspool cleaners Automatic transmission fluid `Disinfectants Engine and radiator flushes Road Salt(Halite) s � i Hydraulic fluid(including brake fluid) ✓ Retrigefants -' n a Ke- t; o"L Ca v1 Motor oils _. Pesticides { NEW .USED insecticides,herbicides,rodenticides) _ Gasoline,Jet Fuel Photochemicals(Fixers) _! Diesel fuel,kerosene,02 heating oil --IO'S ED Other petroleum products:grease, Photochemicals(Developer) luMcants,gear oil EW _�SrrD Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives(creosote) _....' . Battery acid(electrolyte) Swimming pool chlorine Rusiprooters _ .— Lye or caustic soda Car wash detergents _•_'Jewelry gleaners Car waxes and polishes _ Leather dyes. Asphalt&roofing tar Fertilizers Paints,varnishes,stains,dyes _ PCB's i Lacquer thinners 0 er chlorinated hydrocarbons, NEW. USED ine,carbon tetrachloride) Paint&varnish removers,degfossers Paint brush cleaners - Any other products with"poison'labels _ Floor&furniture strippers (including chloroform,formaldehyde, Metal polishes hydrochloric acid,other acids) r/ Laundry so i taro removers —._ Other products not listed which you feel (includin bleach may be toxic or hazardous(please list): =_ Spot removers&cleaning fluids � , (dry cleaners) Other cleaning solvents _ Bug and tar removers i wK�E COvv•�1n OQO�RYMEhT�Cuwa curt Ov51aES3 State In formatlOn BIOCk(Name.Address.Contacts,Phone Numbers.etc.) XPOSURE OR ACCIDENT EMERGENCY CONTACT USE ONLY IN EVENT OF A SPILL,LEAK,FEMEDICAL WASTE TRACKING FORM 3gg State Tracking Form Number(if applicable) ".; INSTRUCTIONS FOR COMPLETING •U) Copy 1 -GENERATOR COPY:Mailed by Destination Facility to Generator MEDICAL WASTE TRACKING FORM Copy 2-DESTINATION FACILITY COPY:Retained by Destination Facility 2.Tracking Form Number Z.; 1.Generator's Name and Mailing Address , , -. `'O 3-TRANSPORTER COPY:Retained by Transporter :e ) COPY i:. ? ) l! ') 4 ACCOUNTING COPY COPY i f;t )`•() I. 4.,.State;Permit or ID No s v,,. Copy 5 GENERATOR COPY:Retained by Genera or .)n rt 1 5 0( - -. K w i • � 1.This multicopY(5-page)shipping document must accompany each shipment of regulated medical - N'i waste. r 4 3.Telephone Number g•Telephone Number completed before the generator can sign thecompleted certification. destination nat n facility. Z a 2.Items numbered 1-14 must be 11c,&19 are optional unless required by the State.Item 22 must be comp Y �..` 5.Transporter's Name and Mailing Address r:.:, �:: t.::a 7.State Transporter permit or ID No. 1.( 6 C 0 t 5 � 16.Transporter 1 (Certification of Receipt of Medical Waste as described in items 11,12,&1 5y5, RIt►WrR 160 +F� -'1' � ;...-• .._ter. ,� � i , '• ;,.. � Date 9.Telephone Number signature .Destination Facility Name and Address A,;; Printed/Typed Name 18.Telephone Number e 8 a l !):I. 17,Transporter 2 or Intermediate Handler t> >• Ir: f.ci�i k. D 1'':!.vt'-' - -- - w'r� (name and address) (' •�T fj �t):;t�; 1D1 State Permit or ID No. t o G Cl 1i c.l�t::I<.(�I'I, I..l cc - a •ir QG�r`f ' -j ^ �0.; �1q9:Statat e Transp orte 0' a Permit° ID No t Yt 13.Total Weight F_ N. oQ 11.US EPA Waste 12.Total Number of Containers LARGE or Volume t ft Description SMALL MEDIUM W -.:r Q. a. Regulated Medical TUB f `` g 20.Transporter 2 Or Intermediate Handler(Certification of Receipt of Medical Waste as described ►�'': Waste(Untreated) BOX '~'' in items 11,12,&13) b. Anatom./Pathol. TUB u Date BOX £ r Signature Waste _ - �- - <�, Printed/Typed Name for consolidated or remanifested waste) State Regulated TUB' rs ewTracking Form Medical Waste;, _ BOX' -w• ` t'fir. 21.N Number 14.Special Handling Instructions and Additional Information f Receipt of Medical Waste as described in it " 22.Destination Facility(Certification oems 11,12,&13) r.:71� }''� 4O r::t)111':I.f'111 /i. `"•f 12,&13 r 7 i I�::11 1 I• ❑ Received in accordance with items 11, a t 11�,.,4j f;) : •:)J'-.::i 1. .t I. r''1.C:h: to F:• 'I 1 r E'Y" rl Yt(t (c.'<<d(f cl. x...- Date signature Regulated Medical Waste,6.2,UN3291,PGII printed/ryped Name p permit or ID no.in box 14.) DOTE 11588 SFa,+ (If other than destination facility,indicate address, hone,and 15.Generator's Certification: ' tZ` 23.Discrepancy Box(Any discrepancies should be noted by item number and initials) = t'= x Under penalty of criminal and civil prosecution for the making or submission of false statements,representations,or omissions,I declare,on behalf of the generator ccfifatel�r)Ids�rij j&1 hd 1:':)Id�st�ie�.yack W Yet that the contents of this consignment are State and Federal laws and lations,and that I have been authorized, 'a tL i �Ctoles,Operation. and labeledinkcc suchje with all asp the person in charge of the gel in writing,to ake such deGarations by 4 ' 1:\4 Date .�. .t- y i Signature lies `}r Pifnted/ryped Name' .) ., .:;ra 1. .I t t.•. !J Delivered: �} : r) f:F 11 p !<):� 1. flamrmablehl'qu'dsWorsexplosives.icked pdoes not include human fetuses,radioactive materials,regulated quantities of hazardous wastes, Supplies rant at the Date - „_ ,..,,,,,e�o-onwledaement • �� /0, LOCATION SEW GE PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS (/F roA US 'Pk BUILDER OR .OWNER H1 tll DATE PERMIT ISSUED DATE COMPLIANCE ISSUED g gam' a Q 114/1�� ItgjI No. '.AQl__/___ Fmc. . ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF.............................................---------------.._........................... Appliration for Diiipaoal Works Tonotrnr#inn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at �. ._ �•.lo ._�..1�........... .. . -•_.... .. .. ................................................ ,p Location• ddre� No. :. c�C:..... .......:/.�k ............... ......... ----.......... . _ _----.. .... .............. ..._..... r Address . ....... ............ .... .. . __....._.._..._..._.........._ ............------•--•.......-•---••---•--.........................._............_..............._ Insta h r Address i Type of Building Size Lot............................Sq. feet ., Dwelling—No. of Bedrooms___. _ ......................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building .. No. of ersons____________________________ Showers a g ___.._.�" p ( ) — Cafeteria ( ) Other fixtures ..............................:.. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. V. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter............... Depth................ x Disposal Trench—No. .................... Width.................... Total,Length.................... Total leaching area....................sq. ft. Seepage Pit No---------------------- Diameter._.................. Depth below.inlei_.____.............. Total leaching area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water......................... f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R.' 0 Description of Soil........................................................................................................................................................................ x v ----------------•-------_._______._-___•-•---•--•--••----------...._----------__._...._......._...._-_....__.__-_---•--......_..----•••---------•--•-•---•-••----------•-•--•-------•------•-----.._..-- w x -----------------------------------•----------------------U Nature of Repairs or Alterations—Answer when applicable...........................:................................................................... --------•..............................................•--•-•--.....-••---_--_-.----._.............._....___........-•----______..._•--•------------____.-.__._.....__.-.______-----___..............__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITi U 5 of the State Sanitary Code.— The undersigned further agrees not to place the system in operation until a Ce4cate Compliance h bee e b the board f h r / .. .. ..... .� ------ ------------------------- Application / - `-• -- - ?te Approv -- - ---- --- =----------------•-•••---••--•--• ......_... ? /-_------ Application Disapprhe following reasons:............................................................................................................... _ .............................•-•----•........._.........-•--•----•-------••____. ..........----•----•...................._.._...._._---..__._........__-----......................................... Date PermitNo........................................................_ Issued.-•-•---........-------•------.___......._•••••-•_....: Date �a FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F.............................-..........-......-.......... Appliration for Eli-gVviial Wv,rkii Toni trurtion Vamit Application is hereby made for a Permit to Construct (. ) or Repair ( ) an Individual Sewage Disposal System at Jl ((,// ?? //�� , . y ..--_...31 .. --� ........ ...........3-_f-._a--..-----•_/-_- .`�:............................................... ocation-,Add No. O r Address V - ............................. .................................................................................................. Ins er Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of-'Bedrooms- __ ( .Expansion-Attic Garbage Grinder a Other—Type of`Building ......... No. of persons____________________________ Showers ( ) — Cafeteria ( ) Other fixtures --------------•."..---------_...._ . >. ...............::.............. .. ...................... W Design Flow:............... .........................gallons per person per day. Total daily flow.._....._.__________..____....._._....____..gallons. a ti WSeptic Tan'k Liquid capacity...'."____gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........ Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... (4 Test Pit No: 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------_........-____-_- R: •---•----....---•---------------•---------------._...--•--------•--.......-----..._..........._..-•-...................................... .........-- 0 Description of Soil......................................................................................................................................................................... x c, w -----------------------------------------------------------------------------------------------------------------------------------•----- .............................................................. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... - ••••-•---••-•-••••-••-•-•--•-•-•-•--•••--••••.............•-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha been s' e by the board f h 7 Date Application Approve-� :. .: 1 -••..................................................................... ..._ 7_.r,z------ ate Application Disapprove o the following reasons:.................................................................................................................. ••---....-•--••------------•-•--•----•----------------------••--...------•------••-•••-••----•-............_..........---•----------------------••-•--------------•----:...._.---•••-••••••••. - Date t PermitNo......................................................... IssuecL......................................................... Date T CO ONWEALTH OF MASSACHUSETTS HEALTH _ Trrtif irate of Tontplianre l T TI FY, That the I dividual Sewage Disposal System constructed ( or Repaired ( ) by......r ___ �'_ ................•---------..................................................................................................... Installer •,- has been installed in accordance with the provisions of TITLE- 5 of The State Sanitary Co pa scribed in the application for Disposal Works Construction Permit No.__ 3_% 4: .__...... dated! - ____________ THE ISSUANCE T CERTIFICATE SHALL NOT BE CONSTRUED- S GUARANTEE THAT THE SYSTEM WILL FU7DM ATISFACTORY. DATE__.........•------ /--- •_.... .........................•--•_.... Inspector.......... ---- ---••--••-••-___:..._....__-_-_____----_.__-__-.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4 ...........................................O F............-......_._.._.._......_............-..._..-._....:.........._........._ I No._� _"Ad_7 r FEE.yA................ :n tog rhii TnnotrWion rrntit Permission is her Re y gr ted• ..... -•---•-••-•---•-•--•• -•-.-•--•••-•--••-•.....-••••••--•••••.....................:...•••-••......_..............--------- to Construct ( or . a n x e ge Disposal System atNo........................... _: . _-__!. -•_.. .......- --•--••--....----•---------------•-----•-•••••-••--••---••- ............................................. Street l as shown on the applicati for Disposal Works Construction Per�m'itt. ...... ,_.......... Dated.......................................... ........................ ...•-•-•••••-----•-••--•-•-----••-•-••••••••-••••---••••••••-•-...-•---••••- L / �� Board of Health DATE_---1Z,-------• - ••---...•-••-•••--•-••-•-•--•-•--•--••••-....... FORM 1255 A. M. SULKIN, INC., BOSTON 1 No. Q�OFT"ETOy� OFFICE OF THE BOARD OF HEALTH OF THE L sAa �,MUB. o TOWN OF BARNSTABLE, MASS. �639q A88. 0 MAY�" -----»:-=�----------f-1------------- 19 741 SEWAGE DISPOSAL PERMIT Permission is ranted to to construct '` '� �- 9 - --- --- —---- -- ------ -- ---. .�----- - ---- -- Upon the Premises of . r ------------- Sketch I{I In the v illa a of 11 100 or Mpre feet from any source of water supply i 20 feet",from building ' 10 feet from property line -14 Hea`fjfi Officer. TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory BOARD OF HEALTH 'y 2.Printers3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANY Jc, J 1 (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS 27 G d e,-10' j ia-6 k W Class: 7.Miscellaneous U*i4kVi3 QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Underground IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers Miscell eous: T � K -- -c;ct 'his wo6. 4v, -j 4. ,4-14 r DISPOSAL/RECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply A4f bf rejece f OS114 (&, c4e1 /0--0-� Town Sewer )$(Public (fie*;lae✓J �i2 �� f- . � Gee a.-1 O On-site OPrivate � ��� � � Ca-ti►�.��� � r@h /� �y_ P/V hY 3. Indoor Floor Drains YES NO U o 'A 10, O Holding tank: MDC 4,C CCU � ac-.. da(�c.�.'ley 1Air. , 0 Catch basin/Dry well ¢ 0 On-site system 4. Outdoor Surface drains:YES NO ➢` ORDERS: 0 Holding tank:MDC i_V1A 'VV3 O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product [YE-S-1 NO 2. (44�40 6L Person s) Interviewed Inspect r D to 1 i •5 -S' ` 3 I�. /o0. It 44 � � !�A.si✓ ` i'�' %Eta � R `7 f ' I , V PO e it 31, SE�''r/c T,4.�✓ = /�GX L�4/ = 2--,owe v.FU. ` T�%7/� _. L��:S/err,/ = •��� �/'G%? Lam.-'7 TO.t� �,�?<s.� •= �Q .S �.. j© .5.F- X /. � = S4 G.�:'Lam• Tom,YQL_ G}A;L y �,l.Syr/_ /7� G F?'a �E ,•C./�7"/remit/ - /" /.r/` M,iAX i Iz eP x, �- '� i ';.d./i� -_„�/'�.,..,•--G'--�/'I�'-- �E`G:/•�;�'E•�_'F"„7�,L,�4�SlJ SU�y:�;v�'�:-'S . , f rlihl Ni •Nr, 193 tJ