HomeMy WebLinkAbout0130 BRISTOL AVENUE - Health -
130 BRISTOL AVENUE-
291-099 iiVANNIIS.
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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.) ou'must obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601. (Town Hall) and get the Business Certificate that is
required by law.t.
DATE: 5 Fill in please:
s'� •.;r 7�,, :� J S OCR
APPLICANT'S YOUR NAME/S: A
�' `y'"'aY;Y •siitr. t. �'` BUSINESS YOUR HOME ADDRESS:
' e!!lys'� TELEPHONE # HomeTglgp �! e�
E-MAIL:
NAME OF CORPORATION:
NAME OF-NEW BUSINESS TYPE OF BUSINESS
IS THIS A HOME OCCUPATIPN? YES NO G
ADDRESS OF BUSINESS. . f� MAP/PARCEL NUMBER ! V I [Assessing)
When starting a new business thePe 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 lain St. [corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits'and licenses required to legally opera your b
operate in this town.
1. BUILDING COMMISSIONEFf'S OPFICE MUST COMPLY WITH HOME FAILURE
ILU OCCUPATION TO
This individual has bee f r ed of an e e uirements that pertain to this type)obusinessRULES AND REGULATIONS
** r?LCaMF'LY MAY �IUL IIVII�lI�5:
Authorized Sin ure n �
COMMENTS: x
aa
Ct: - c ;
2. BOARD OF HEALTH
This individual has a nn i�a the rmit requirements that pertain to this type of business.
AI.I
Authorized Signature**
MUSid11Ap1 +
COMMENTS: HAZARDOUSMATERIALS'.0G
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 Dater
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: P A�
BUSINESS LOCATION: 190 B✓Z i.5�O L A'✓E INVENTORY
MAILING ADDRESS: TOTAL AMOUNT: .
TELEPHONE NUMBER: 9 T 601 LI 9_i- 2114A I
CONTACT PERSON: QA)kkaJAIZA 2-NIA 2) f;' So% ra
EMERGENCY CONTACT TELEPHONE NUMBER: �J'�-Q�o 1'I�� 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 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)
i 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)
Epulk/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
U 1 OY�aints, 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):
� I _
Metal polishes 'f Vests , A U 1(L
Laundry soil & stain removers
(including bleach) Z.�Q a 01A ipG i h 111 r d
Spot removers &cleaning fluids y —T
(dry cleaners)
r I (I w1.C1 uY r
Other cleaning solvents
Bug and tar removers
Windshield wash Vb�r
'
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's gnature Staff's Initials
I
Town of B r nstable. P#
Department of Regtilatory Services ' I
Public Health]Division Date / 8
163y. tee$ 200-Main Street,liypnnis MA 02601 ;
'�rFD µ►'l� �
q. Date Scheduled 1 Time ;U' Fee ee Pd. �• �,;.
oil >S'z�itability Assesstaient fop SewnTe Disposal
Perfoiined By:
eV
Witnessed By:
i
LOCATION & GENERAL INFORMATION
Location Address 13D g Vj STo L A-vie, Owner's Name Cr--Q A U p Q
Address Po 8
Assessor's Map/Pitcel: / V 1 I Engineer's Name Me 7 J'tr^s
NEW CONSTRUCTION REPAIR '\ Telephone#
Land Use Zen l 0Ed")V-'',' Slopes(C/O') •� � Surface Stones'y /6-Ya
Distances from: Open Water Body Possible Wet Area? ft Drinking Water Well
I '
Drainage Way f[ Property Linc ! ft Other ft
SKETCH:($treet name,dimensiods of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)
. i
. i
I
I
Parent material(geologic) e X�,. 0 I Depth to Bedrock
Depth to Groundwater. Standing Water in Hole:* i
Weeping from Pit Face
Estimated Seasonal i fth Groundwater
D +RMINATION FOR SEASONAL HIGH WATER T"LE
_., I i ln.
Method Used: >` In, Depth to soil mottles:
Depth Cibperved standing.,'n obs.hole: in. Groundwater Adjustment it
Depth toiweeping from side of obs.hole: Adj.factor,, ._v- AdJ.Oroundwaterl evel„ems
Index Well# Reading Date Index Well levtl
I
PERCOLATION TEST Date
Observation I Time at 9"
Hole# '
i°_ Time at G"
Depth of Pere
Time ff'-O')
Stag Pre-soak Time.@ -� its
--
i
End Pre-soak
Rate MinAnch !^
.t Additional Testing Needed(YIN)
Site Suitability Assessment Site Passed /' Site Failed:
le Data To Beompleted on Back
Original:.Public Hce lth Division Observation Ho —
***If Percola''n test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1) week prior to beginning. '/�
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil ' Other
Surface(in.) ;USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.To Gravel
=ava l./RI"„IG�ICjVt � l��
Wrt^1Z11 anti S nj [a�ti3l-✓
LOCA
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) ;USDA) (Munsell) Mottling (Structure,Stones.Boulders.
Consistency.%b Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (MUOSCII) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel
DEEP OBSERVATION HOLE LOG Hole# N
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency. Gravel)
F
Flood Insurance Rate Map:
Above 500 year flood boundary No— Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring perv' us material exist.in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring per ious material?
Certification 01
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of En ' on' ental Protection and that the above analysis was performed by me consistent with
the required train ng, p ise andVxrience described in 3:10 CMR 15Signature `/ Date
Q:\SEPTIC\PERCFORM.DOC
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: U Es Fill in please:
� APPLICANT'S YOUR NAME/S: Y.s,e� E4 (j6' zrl a/V
tSu'}.:Ef14 v' f t
N BUSINESS YOUR HOME ADDRESS: ioti, s b AV Nq hhi s 11tx
w£� ..... TELEPHONE # Home Telephone Number
NAME OF CORPORATION: -
NAME OF NEW BUSINESS TYPE OF BUSINESS G'Qh
IS THIS A HOME OCCUPATION? YE NO
ADDRESS OF BUSINESS reMAP/PARCEL NUMBER OV (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. BUILDINjal
ER'S OF ICE
Thisnc o d f a pe it re uire ents that > rtain to this type of business. MUST COMPLY WITH HOME OCCUPATION
RULES AND REGULATIONS. FAILURE TO
ri i t ** COMPLY MAY RESULT IN FINES.
OM EN
' 1
2. BOARD OF EALTH
This individual has been inf r e-d of the permit requirements that pertain to this type of business. MUST COMPLY4.TH ALL
�1�`�` HAZARDOUS MATERIALS.REGUU,-
Authorize Signature*
COMMENTS: No LJIL-ztz_o
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 ;�, Health Inspector
oFt t Office Hours
o Regulatory Services 8:30—9:30
Thomas F.Geiler,Director 3:30—4:30
• BARNSrABL6.
b 9 �0r Public Health Division
A�Fp��,tA Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508462-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE
Date: 2/6/09
1. General Information: Size of Property: 0.26 acre
Address: 130 BRISTOL AVENUE HYANNIS MA 02601 Map 291 Parcel 099
Name:VfA\t-CVlo ce rc4 ony-c Phone#: _501� .
2a. How many bedrooms exist at your property now? 4
2b. Are you planning to,add any bedrooms? NO If yes,how many? 0
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?4
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing
rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways.
Please label each room clearly:
3. Is the dwelling connected to public sewer? Public Water, Gas, Septic NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE or OU S DE a Saltwater Estuary Protection Zone?
5 . Location of dwelling is INSIDE or / OUTSIDE a Zone of Contribution to public supply wells?
6. Is the dwelling connected to PUBLIC WATER? 1 YES
7. Is a disposal works construction permit on file? YES or NO
8. If yes,how many bedrooms were approved according to this permit? Bedrooms.
9. Were any building permits obtained for construction of additional bedrooms? YES or NO
10. Is there an engineered septic system plan on file at the Health Division? YES or NO
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
-------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY J _ I
The Public Health Division has no objection to bedrooms at this property.
Special Co ditions: Ott-,Let o, e (L �e,,•,� A 6�
.Q J— ..M I/M / `� et Ili `.\i CT SC,
Signed 4 Date: L)fFo'J'A
Q;/health/wpftles/amnestyapp
r KUl'I r HR 11IU. J U 1. ✓JJ eUUt) 11.44HI'I r 1
TO:. C,t d y LtA, b R,vW S
-- I
occ;rc
3-0'x 3'-0' 2'4'x 9"6' o b 2-4'x 3'-6'
BATH
N MASTER
k KITCHEN b - —g 6• BED
DINNER b I
3 0'x 6'4' 2'-4'x 6'-8' 2 14'x 6'-8'
201-8 b—......
-8'x 6 2 4 'x 6'-8' g-0'x 6'-6' N
N
N �- 9'-0'
w ,o -
LIVING _ F k
BED- BED N
q
6'-8'x 4=0' '-0'x 6'.8' 2'•4'x 3W 2-4'x 9-6'
130 Bristol Ave
Hyannis- MA
MAIN FLOOR
48'-0•
26'-0" T-7' 14'-5'
0
- v
2,-
w .f' 5'-8•,Y
ai
KITCHEN 2.0. �`
-10'�r-10 OFICCE Q
4'-0"x 6'-8" 21'-0" -k- J I ' - -I
to m
2'-4"x 6'-8 0 2'-0"x 6'-8"
T
I
k k l e 4=o"x 6'-8" T-0"x 6'-8" C. � 2'.4\x 6'-8" 2'-6'x 6'-8 N
—=r
8'-9. t. 9'2° 8'-1 7 �5'-�' co
35'-8"
Ni
co co ••
'GARAGE
BEDROOM k
3'-0"x 6'-0" 3'-0•x 6'-0" '-0"x 6'-8" 1 3'-0"x 6'-0° 3'-0"x 6-0'
6'-6" �' 8'-8' 9'-1" i' 9'-1° 8'-7• 6'-1'
48-0'
Cc Se rV\-Q V\-
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�• Commonwealth of Massachusetts 5a O
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary AssessMents
w 1.30 Bristol Ave.
Property Address
Paulo Cropalato
Owner. Owner's Name
information is Hyannis Ma. 02601 10/06/2008
required for. y
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be-al-tiered in any
way. Please see completeness checklist at the end of the form.'
Important:When filling out A. General Information
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
Q P.O.Box 763
Company Address
-Centerville Ma: 02632
City/Town State Zip Code
(508)428-4028 S14454.
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 Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
- 10/06/2008 c; c,
Inspector's Signature Date
— I t.
(J1±
The system inspector shall submit a copy of this inspection report to the App@bg Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is s"red.systeri'or
has a design flow of 10,000 gpd or greater, the inspector and the system owne shall sp*rhit the
report to the appropriate regional office of the DEP. The original should be.sen 16 tho ysteat owner
and copies sent to the buyer, if applicable, and.the approving authority. r
****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.
t5ins-09/08 - Title 5 Official Inspection Forth:Subsurface Se tsposal System.-Page 1 of 2
No. • y —��i"✓ Fee 150
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. _l/
. Yes
PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE,MASSACHUSETTS
0(ppiication for gw5ar *pgtem Construction 3permit
Application for a Permit to Construct( )Repair( ).Upgrade( )Abandon( ) keomplete System ❑Individual Components
Location Address or Lot No. , Q (I � Owner's Name,Address and Tel.
No. -
Assessor'sMaOarcel aai_
Installer's ame,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms t Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
OtherFixturess t
Design Flow gallons per day. Calculated daily flow "�� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1S02) Type of S.A.S.
Description of Soil ►nr�� S lA
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 th tronm ntal Code and not to place the system in operation until a Certifi-
cate of Compliance has b tss e y s all .
Sig d Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERT"t V`the On-site Sew2se Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by S C .
at O { ST nl vE c.v` t S has been constnt d i�o accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. oo cl-3 I b datedZ i t/
Installer Designer
The issu a f-thisp(�rmit shall not be construed as a guarantee that the sys will f lion as dent 1 e p
Date /U�� Inspector � I &j W
--------------------------
Fee ,
l
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MA5SACHUSETTS i
migpo!5al &p!6tem Con6truction Permit
Permission is hereby granted to Co truct( Repair( _<P_91�de( )Abandon( )
System located at
V,w.
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 Condit'
Provided:Construct' n mus be completed within three years of the at of this e
Date: ������ APProved b ���
TOWN.OF BARNSTABLE
LOCATION ' 13 D�>�S-�L �\J r SEWAGE
VILLAGE 14 N N S ASSESSOR'S MAP & LOT 0�9�
INSTALLER'S NAME&.PHOKE NO.
SEPTIC TANK CAPACM � � >`'I 16-�
LEACHING FACILITY: (typo) /(size)
NO.OF BEDROOMS
BUILDER OR OWNER �w �-
PERMITDATE: COMPLIANCE DATE: `�a 0
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
o .
it
Dr�re'
T:: RojV I .
Dc� , JUG b
l
I
Commonwealth of Massachusetts 5a O
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M `130 Bristol Ave. 4 = 029l-Q Q,
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at.the end of the form.
Important: 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
use the r eturn Name of Inspector
key. Capewide Enterprises,LLC.
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S 14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/06/2008 / c�i -z
Inspector's Signature Date '
r.It�
The system inspector shall submit a copy of this inspection report to the Apprbu'ng Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is share( ysteri'or
has a design flow of 10,000 gpd or greater, the inspector and the system owne shall submit the
report to the appropriate regional office of the DEP. The original should be sen to the stem=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.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Se isposal System-Page 1 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A;B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the followirig statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ 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.
❑ The system has a septic tank and SAS and the-SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of'custody must be attached to this form.]
a ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 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
i
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered.yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® 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?
❑ ® 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?
® El information
the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and.location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 440
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1500 gallon septic tank,Distribution box and one leaching trench.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage.system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings" if available last 2 ears usage d 2006:45,000
( y g (gpd)): 2007:84,000
Detail:
2006:123 gpd 2007:230 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
i
Water meter readings, if available:
l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and•
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach.a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
System installed 2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
14"
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from.private water supply well or suction line: 1 +
fee et
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):
Depth below grade: 14"feet
Material of construction: ,
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑- No
Dimensions: 1500 gallon
4"
Sludge depth:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? measured
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 septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
I �
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
r
Alarm level: Alarm in working order: ❑ Yes - ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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 Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
I
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1-75'x4'x2'
❑ 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 dry soil.No signs of hydraulic failure.No ponding or damp soil.Leaching trench stone appeared
dry at time of inspection.
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
t5ins-09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14
f _
Map Page 1 of 2
16
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http://www.town.bamstable.ma.us/arcims/appgeoapp/`map.aspx?propertyID=291099&map... 10/7/2008
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma.' 02601 10/06/2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: Bottom of trench 20'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ 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:USGS Observation Well Data. USED:Technical Bulletin 92-000-01 plate#2 annual ranges of
groundwater elevations.
I •
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Bristol Ave.
Property Address
Paulo Cropalato
Owner Owner's Name
information is required for Hyannis Ma. 02601 10/06/2008
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® .Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
r
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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)
; on PA w
DATE: �'"�2
Fill in please:
W
APPLICANT'S YOUR NAME: 1v
.�. BUSINESS YOUR HOME ADDRESS: 'ru
TELEPHONE # Home Telephone Number -
NAME OF NEW BUSINESS: T S TYPE OF BUSINESS. ill^ ' '
IS THIS-A.HOME OCCUP..IO ?;.. YES -_NO:.
ave you :. 1fES �N0 q
ADDRESS OF BUSINESS -1 4 p MAP/PARCEL NUMBER
/Ll�SS
When starting anew 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 i formed any permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
vj 2. BOARD OF HEALTH
This individual hap been i rmed th mit requirements that pertain to this type of business.
Au orized Sig ature**
COMMENTS: �� 1A-1 GZ a__
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
j This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
r
Dater
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAMEOFBUSINESS: ` i4r�Y;rS i�►/�r/�1%t� `��
BUSINESS LOCATION: 130 PLAILVZ IfV 14y92VEV •A —/yl?� INVENTORY
MAILING ADDRESS: 13&k 1 (9'4-4 +�! '-'"�5 TOTAL AMOUNT-
TELEPHONE NUMBER: 0
CONTACT PERSON: PAlkio C," T'p
EMERGENCY CONTACT TELEPHONE NUMBER: �5 �- `�f e' 2l Cl MSDS ON SITE?
TYPE OF BUSINESS: ro(v &-
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
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
Misc. 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 Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes CL�f 4'X� Other chlorinated hydrocarbons,
i Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor &furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers
(including bleach)
Spot removers & cleaning fluids
(dry cleaners) 77CA=
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
TOWN OF BARNSTABLE
# �3/D
LOCATION _; o, (� 3ns�L A�1'r SEWAGE
VILLAGE A-1Af1J S ASSESSOR'S MAP & LOT oZ9/-
INSTALLER'S NAME&PHONE NO. CD
SEPTIC TANK CAPACITY
c /
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS_
BUILDER OR OWNERo Lev .
PERMITDATE: COMPLIANCE DATE: c -1
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
o
4
J
� \�
0
r .�
i
No. 'goo —�/i� Fee �Q
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Miqual *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) )�Gomplete System 0 Individual Components
Location Address or Lot No. 1 (Q � Owner's Name,Address and Tel.No.
Assessor's Map/Parcel aai—
Installer's e,Address,and Tel.No. ` Designer's Name,Address and Tel.No.
� 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 �'l gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1SQ D Type of S.A.S.
Description of Soils S 19
Nature of Repairs or Alterations(Answer when applicable) �4 ylJ
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 rronm ntal Code and not to place the system in operation until a Certifi-
cate of Compliance has b issue y is Halt .
Sig d Date (a
Application Approved by Date g-,
Application-Disapproved for the following reasons
Permit No. w Date Issued l
No. /z * 3 _ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftplication for 33iopozat *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) feomplete System ElIndividual Components
` Location Address or Lot No. 1 (1 U� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
ti
Installer's e,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms "t 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 t"l 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)
Date last inspected:
n_0
Agreement: rt�,
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 th nviValt
nta ode and not to place the system in operation until a Certifi-
cate of Compliance ha�een'd by Ibisthrt'buHt' Sig � Date
Application Approved by Date 0-0 Y
Application Disapproved for the following reasons
n Permit No. zl _ 3 Date Issued
I
—————————————————————————————————————--
THE COMMONWEALTH OF MASSACHUSETTS a
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIF at1t_he On-site Sew2ge isposal System Constructed( )Repaired ( ) Upgraded (V)
Abandoned( )by � o�J� S� �C—
at � f`SS oL. S O� has been constrtyctel� accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 3 dated l4.•// /
Installer Designer
The issua ce fpis i. ut shall not be construed as a guarantee that the sys will foltion as desMe
N Date •r• % Inspector YC
i
_ —
No. �""�� ;3 /D---------- -------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
�N!5pozal *pgtem Construction Permit
Permission is hereby granted to Construct( Repair( ade( )Abandon( )
System located at
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 conditi -
Provided: Construction mus be completed within three years of the ate of thije **
Date:_ �� Approved b
Sep - 20-01 13 : 52 BARNSTABLE HEALTH DEPT 50879d6304
t
. sns;ol
!�OTTCE: This Form Is To Be Used For tb.e Repair Of Failed
Septic Systems Only.
PERCOL,aTION TEST Af\M SOIL EVALUATION EXEMPTION
FORM
CIO DO - &tAX -, hereby certify that the engineered pian signed by me
dated to 04 concerning the property located at
V C" meets all of the
icl'o•ving ::nteha:
• This failed system is connected to a residential dwelling only. There are no
=or-vnerzia! or business uses associated with the dwelling:
T? e soil is ciass!�:ed as.CLASS l and the percolation rave is less than or equal to 5
-n:nut:s per Inch. The applicant may use histo'ncal data to conclude this f3c: or may
.:onduct ?Wirnwar;- tests 3t the site without a health agent present
• There :s no increase to now and/or change in use proposed
• Chere a'e no vanances requested or needed.
• The bottom of the proposed leaching facility will not be located less than fourteen
:I=j 'ee: 3onve the maximum adjusted groundwater table elevation. �Adiust the
riundwater table using the Frimptor method when applicable)
Please complete the following:
TOF •DI Ground Surface Elevation (using GIS information)
6 C.W' Elevw:on adjustment for nigh
ITT=T.REFN CF BETWEEN A , d B
S'GYED _ DATE:
"_--- --------• ._.._— NOTICE
:3as.-c i-on, t;"e atove information, a reoair permit will be issued for .ocdroorr.s
Ta,.,rr,ur:. :`:o :ddiu^nal bedrooms are authorized to t` c future wi°.hout en,tncerec
i =syste^s plans. --- —
1!:11n!r,:oci �ciccamp
Permit Number: Date:
Completed by:
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: Lot No,
Owner: Sc� Address: "C(Y
Contractor: �Jlrr� Address: �G�nccn
Notes:
STEP i Measure depth to water table
tonearest 1/10 ft. .............................................................................. .Date 0/y
mon h/d
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well....................................................
i
OWater-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...........................
mont /year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and-water-level zone (STEP 2B)
determine water level adjustment ..............................................: c� L
STEP 5 Estimate depth to high water
by subtracting the water•
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) ...
...............................................:.................................................
i
h
Figure 13.--Reproducible computation form.
I
15
TOWN OF BARNSTABLE
j LOCATION ' 13 0 ins SEWAGE #
VILLAGE t'I�IA N N�S ASSESSOR'S MAP& LOT all
INSTALLER'S NAME&PHONE NO:
SEPTIC TANK CAPACTry,,
LEACHING FACILITY: (typo) 31��1`��'�- (size) � -1 7
NO.OF BEDROOMS
BUILDER OR OWNER �w L
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of Teaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
Within 300 feet of leaching facility) Feet
Furnished by
L/
o .
A-1t � I
DOFF
09/19/2014 17:24 r8A °
'gown of Barnstable
Regulatory Services
Q► Thomas F.Geller,Director
's Public Health Division
�033�, Thomas McKean, Director
200 Alain Street,Hyannis,MA 02601
Fax: 508-790.6304
Office: 508-862-4644
ner Certification Form
Installer&Desi
Date: 6/22/04
En�'ironmental Services Installer: Roberts Se tic Service
Designer: Sha Address: 5 Trenton Str et
Address: 34 Thatchers Lane yannouth A
East Falmouth MA 02536
Roberts 5e tic Service was issued a permit to inst la
On 6/21/04 (installer)
(date) drawn b
septic: system at 130 Bristol Av aunts based on a design
p (address)
Sha Environmental Services dated 6/18/04
(designer) ove was according to
certifyXX that the septic system referenced Dyed changes installed
as lateral a elocution of the
I which may include minor appr
—the design,
distribution box and/or septic tank-
es i.e.
component
i that the septic system referenced Sabove nyertical lrelo at on o or with Ma changes
comp or
I cent fY Regulations' Plan revision
— greater than 10' lateralbut in accordan eewith State &Local
of the septic systemdesi designer to follow.
certified as-built by gn
•tH v>:�s
4 G L
(Insraller's Signature)
ii1�,1T8�
• ��1 T
(Affix De 1. ere)
f'M(Designer's Signature)
PLEASE RETURN
TO BARNSTABLE PUBLIC HEAL BUTH TIIIIOS F W I AAT�
C1F COMPLIANCE FILL NOT BE ISSUED UNTIL
ILT CARD ARE
RECEIVED-8 :. BAIt1�STABLE PUBLIC HI±,AL H DIVISION.
THANK YOU.
Q;FicajtWSepticiDcsigncr Certification Form
Y PAGE:1
JUN-23-2004 WED 04:51AM ID:
LOCATION SEWAGE PERMIT NO.
/ 3 d�.Cis l�
VILLAGE
INSTALLER'S
NAME & ADDRESS
® U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
t
.� � ��
i ty
Ir
I �'
v �
' - .R -
Nro....`.......:2......... Fmc.........15..Q0....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF' 'HEALTH
...................T.O.Wn..........OF........Barns.tabl.e-................................................
Appliratiun for Di"uua1 Workfi Tunitrnrtiun rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
IN...BriatQl..Ayte...,...Hyannis......02-601.... ..................................................................................................
Location-Address or Lot No
Fd3m.....Skales..............owner............-----------------..........--- .13Q.:Hris-t.ol...kvEAa ASH
a A..&...B...Ces-sRoo ... rvjee................................. .125.. ...02601
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms---.-_---------3......................Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type of Building ............................ No. of persons....4__.__._.__._.___.____ Showers ( ) — Cafeteria ( )
G" Other fixtures -------------------------------- -
d
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 W Septic Tank—I.iquid'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........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ..•••••--•--•••-------•---•••---•--•-••----••••••-•••••••-•••-••••-••-•-••-•-•-••-•..........................................................................
ODescription of Soil------.....Sand...&..Gravel......................................................................................................................
x
W •••••-•--•-•.......-----•-------•-•-•---•--------------•••-----••-----••-•-•-•--••--•-•-•-••-••---•••••••-••••••-•-•-•------••••----•--•----•-•••-••••••••••-----••..................••-•--•........-_•-
UNature of Repairs or Alterations—Answer when applicable...Installat i.on....of---a...1-t-0.0.0---gallon---.
pre.-cast->...s tone...packed...l eanh...pit.........................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the T provisions of LNLZ
p S of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the bo o iealth.
Sign 417_.-
Date
Application Approved BY ... y�J l !� :. Date
Application
Date
Application Disapproved for the following reasons---------- ...................................................................................................
..•--•••-••-•••••-••••.......•--•••--••••...............•-••••••-••-•-••••-••-•••-----------•-----........-•--••--••-••••••••----••------•----•-•-••---••-•------•--•-•---•----•---------•--•••••--••-••.
Date
Permit No.-----•----•----79L—................................ Issued_...............411.5179....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................11110.Wn...........OF........Barnstable..................................................
Appliratiun for Diupuuttl 19orkii Tonutrurtion jimnit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
1,3Q...ftLeAml...Aue...,....Hyannia,.A2601.... .................................................................................................
% or Lot No.y;•. :.:. Location-A dress
wdw.-=&k-o-14vx..•.............................................................. .13.0t...Brie tool---Ave.- a AMIB. 02fiQl...
Owner Address
... .._ ...O.�.IIAP.0.01...SAIVIC-0-................................. ....0.2_6.Ol
Installer Address
Type of;:Building Size Lot............................Sq. feet
�. Dwelling—No. of Bedrooms................3.........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons.._. Showers — Cafeteria
Otherfixtures ---------------•--------------------------------••----••••---•-------•--•••-•••••••••••-•-......_..•••.......•-------•-•--•--••------......-----.----
WDesign eFlow:._:. .................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity._......_...gallons Length................ Width................ Diameter................ Depth................
x Disposal,Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other )}�*wibution box ( ) Dosing tank ( )
�' PercojQ
l 1?,Test Results Performed by.......................:.....................................•--•--•--•_-• Date........................................
aTest Pit No. I:...............minutes per inch Depth of Test Pit............_....... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------------------------------------••--......•------------•---......................----.....--.........................................................
ODescrip4on of Soil............Sand...&...GX8_V01......................................................................................................................
U ..........................•------------•-----------------...-•-•-------------------•---------•--.....-•---•------•-•-•---------------...----....-----.........---•-•--------------------------------
W 3.. .
UNature of Repairs or Alterations—Answer when applicable.---Installation----0f---a...1,.000---gallon---.
pr-e-...6 :t.,'-`8tone=-=pack.ed...leach...jAit.---=----------------------------------------------------------------------------------------------------
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 has been issued b the bo v o ealth.
O.
Signe -tF�' ...................... .....4./171.7.9.......
Date
Application Approved BY.........f l.....C....r. _. hLl......� 9...................................... --•---------.411-7/ .......
Date
Application Disapproved for the following reasons:------.....✓-----------------------------•----------------------------------....---------------•-•••--.......---
...................••--•---.........•-------•-••-----•--------------•-•---•--••---------•----•-------•--•--•••-•--••-------•--•-•---------•-••••••-••-•••••---••••••••••-•-••-••••••-••••---•---••------
Date
Permit No................. ...................••••••••••... Issued................4/ - 9
17 ....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... . . ...............T+j).Wn..............OF..................Barnstable...................................
T-r#if i "tr of Tompliaurr
TO CERTIFY, That the Indivi ual Sewage Disposal System constructed ( ) or Repaired (X )
THIS IS TO
Sarlrice.,--.12 _.- .........
Installer
at--- Hyanntm,----02£Dl_----_ ..................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._._.7.9-......?_l.f......... dated------------4/17l7q...............
THEASSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION
FUNCTION SATISFACTORY. �j
DATE.:.:.:.......
!••....-zS---.:..7.7................................' Inspector..-•----•---��'�R!%=/k
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF............;3asne uable.............•••.........................
l� ..t� .. FEE 5.e.9 9......
No.. 4--.... -( .
Disposal Workii Tonutrurtion rprmit
Permission is hereby grantedA..Z:..R..�'anapaal..._ P,�u ,CL',-•--1.Z$-• is les= •--`���3iS',- --:-=Y4r 3Y218
to Construct (� ) or Repair ( X) an Individual Sewn Disposal System
at No.- � =r oz Ave. .,t...HY.�nnie.....0?�0.1......" "dw._..Sk.le.r--------------•------------------............--
street '7
as shown on the application for Disposal Works Construction Pe it N . -9 ------ Dated....4/.. 7119..................
Board of H
DATE_:_-..:::.-{---•--�•--•••••-•...........................•--------•.........
FORM 129f .;*110BB'S & WARREN. INC.. PUBLISHERS