HomeMy WebLinkAbout0370 COMPASS CIRCLE - Health 1.,370 COMPASS CIRCLE,HYANNIS
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Town of Barnstable P# ( � J
Department of Regulatory Services
> 8 � : Public Health Division Date
MASS
039. �� 200 Main Street,Hyannis� MA*02601 .. v . .
00 * `
Date Scheduled/®Ay Time Fee Pd.
Soil Suitability.Assess ent for Sewage. isposal
Performed B9 tJ/ 1� Witnessed By:
LOCATION&GENERAL INFORMATION
Location Address 2�7.t7 G o1-r�p��rr� Gist, �/�! Owner's Name
Address
Assessor's Ma /Parcel: O
P / Engineer's Name 4! U vim
NEW CONSTRUCTION REPAIR y Telephone#
S
Land Use Slopes(40) Surface Stones '
Distances from: Open Water Body ft. Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of Jot,exact locations of test holes.&perc tests,locate wetlands in proximity to holes)
�1
Parent material(geologic) P=1'C/(4 Depth to Bedrock
Depth to Groundwater. Standing Water in Hole:, U^�L Weeping from Pit Face
Estimated Seasonal High Groundwatert
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: __ in.,. Depth to soil mottles:
Depth to weeping from side of obs.hole: —_ in, Groundwater Adjustment fit.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater lAvel.n
PERCOLATION TEST bete, Thee.
Observation
Hole# Time at 9"
Depth of Perc w Time at 6"
Stan Pre-soak Time @ Time(9"-6")
End Pre-soak r.
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division. Observation Hole Data To Be Completed on Back-----------
.***If percolation 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.
Q:\.SEPTICVERCFORM.DOC _
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistencv.%"Gravel)
tr S Q
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
,tom Consistencv.%Gravel)
r
DEEP OBSERVATION HOLE LOG Hole#.
Depth from Soil Horizon Soil Texture Soil Color Soil Other '
Surface(in.) (USDA) (Munsell) Mottling ' (Stiucture,Stones,Boulders.
Consistency.%Gravel)
r `
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders.
Consi ten
t
t
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 pervious material exist in all areas observed throughout the
area proposed for the soil a 'sorpf n system? ---F
If not,what.is the depth of natur ly occurring pervious material?.....
Certification
I certify that on �� R (date)I have passed the soil evaluator examination approved by the
Department of Enviro me tal Protection and that the above analysis was perfor b me consistent with
the req ' ining,exper' e and ri nce escribed in 310 CMR 15.017. 9
Sign ure
Date �Z Z
Q:\S.EPTIC\PERCFORM.DOC
Z-,) - TOWN OF BARNSTABLE
LOCATION.--,70 ar�V-"SS ' n P SEWAGE #
`3!O
VILI;AGE 0.e-,A,S ASSESS R'S MAP &LOT:RR9 3
.. _ NAME&PHONE NO. l`
SEPTIC TANK CAPACITY ,/000 Q/Q/• / 4'✓1 -. 1�e r�t[D%�7�I ,�(
LEACHING FACILrTY: (type)�i�� C_ % � (size) I 'C 0 G�r
NO.OF BEDRO
BUILDER O OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the: f
Maximum Adjusted Groundwater Table and Bottom of Leaching Facili' 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 3 et of eaching fac' ) r Feet
Furnished bv� 1` l)
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,�
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TOWN OF BARNSTABLE
LOCATION ��Q �®���fJ Boa' SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY,-'f->6,-,'9'
LEACHING FACILITY:(type)
NO. OF BEDROOMS
OWNER �.��/�f
PERMIT DATE: 10�2 �.3`® o� COMPLIANCE DATE: ® 9
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 L-aching Facility(if any wetlands exist
within 300 feet of leaching_facility). / feet
FURNISHED BY
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. No. U Fee 16 J,_�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: LZ
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for �Btgonl i§p5tem (Con!6tructton Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑.Complete System Individual Components
3�o comrF34-r-r'
Location Address or Lot No. Owner's Name,Address;and Tel.No. ����e f.
Assessor's Map/Parcel 3)a c C"^OCi .0v' Cla• oo 'v
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
X—P 3 3 .1/,1
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Type of Building: t
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building �J. No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �' gpd Design flow provided '3�® gpd
Plan Date - �` �� Number of sheets Revision Date
Title
Size of Septic Tank ��'` 7` 6�' /aoo Type of S.A.S. p.H r w
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this$daQ of Health.
Signed Date
Application Approved by MA t, Date .T d
Application Disapproved by: Date
for the following reasons
Permit No. a Go�� I Date Issued 1 Z-3o -UCIi
-- -- - - — - --:ter ---- --- —
No. Uo I - q�L a i Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered icomputer: Iz—
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETT6 Yes
Application for Oigpogal A&pgt18m Cow6tructiou Permit
Application for a Permit to Construct O Repair( ^Uade O Abandon O ❑ Complete System Individual Components
om�yq .
Location Address or Lot No. yy `Owner's game,Address;and Tel.No.
Assessor,'s,4ap/Parcel }'�/0 9' �a c �+f'. rj- cla ,yy e'
Insiiller%s Name,Address,and Tel.No., Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building 40e !-V", No:-of Persons Showers( ) Cafeteria( )
Other Fixtures,
r Design Flow(min.required) ' gpd Design flow provided gpd
Plan Date -tea --A 7_c9 Number of sheets Revision Date
Title .
� r 1 J
Size of Septic Tank �N -r7` , � /a0o Type of S.A.S. S"� ����% ,, �„��c r,
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:j .A
;Agreement: /
The undersigned agrees to ensure the construction andimaintenance of the afore described on-site sewage disposal system in
accordance w th the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of,
Compliance As been issued by this r of Health.
i Signedl� Date
Application Approved> , tin Date ) — U - CJ
Application Disapproved by:" Date
for the following`reasons .'
k,Y
Permit No. ' �u o qg Date Issued
ti.
—————————--
_ r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (x) Upgraded ( )
Abandoned( )by
at 'C 0��.�1-r- c/4?• �,i.S� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. Do')� - V7,t dated ;Z -30 -vG
Installer Designer v i 0 40r
#bedrooms 3 Approved design flow 3 j5�-® gpd
The issuance of thispermit shall not be construed as a guarantee that the system will fa c ion as desi ed.
Date Inspector/
————————————————————————————---------------
No. 2 oo Y1?' Fee U d
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS �.
°h 1=i0po$at *p$tem Construction Permit
Permission is hereby granted to Construct ( ) Repair (x,) Upgrade ( ) Abandon ( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
f l
Date 1 /Z p/.) Approved by
Jan 06 10 08: 26a p. 1
Town of Barnstable
Regulatory Service;
��P T
Thomas F.Geiler,Director
bn�Na'TAA6�,
Public Health Division
Thomas McKean,Director
200 Main Street,Hyan-nis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Desigacr Certification Form
Date:
Designer: _Mt__ Installer.
Address: rt �L, .` Address: (141
On^ ( was issued a permit to install a
(d tc) pp (insUiller)
4 septic system at `� ID „based on a design drawn ley
(address)
dated
(designq)
certify that the septic system referunt.e;d above was installed substiuWally accordin? to
?.:he design, which may include minor at proved changes such as labt='l relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above Was installed with'rr*r changes (j,F.
greater thm z W lateral relocation of the SAS or any vertical relocation of any componeaat
of the septics5ystern)but m accordance with State&Local Regdlations. Plan revision or
certified as-bi+1'`lt by desa.gner to follow.
tH OP Mqs�
(Installer's Signature) h' '* m
No.M6
4 prAiaIP
Signature) (Affix-- .e ,T'9$fame Here)
PLEASE RETURN TO BARNSTARLE4UBLIC ,AEAif.NEO Dl'lr>tSION. C: RRTIFI;CATE
Off'. C4i PLTANCF WI>(L' NU.T SE - SUED-UN BO'Y' t:-' S°1?QRM AND A_
BU[[,T CAY2D ARE}2F,CETVED B'Y.T)�lC$41' NSTAULE PUBLIC REA D)�VISI
THANK YOU.
Q: F,Cal t 80ptic/Ucsirncr Cart]ficApn Forrr,
310 q '
BORTOLOTTI CONSTRUCTION,INC. �ECEIVE�
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 JUL
�g�b
508 771-9399 508-428 8926 '`FA(X: 508-428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION ` S y`¢
Property Address:_
Date of Inspection: Inspector's Name:
Owner's Name and Address:
c i o
CERTIFI ATIONSTATEMENT!
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal 511stems. The System:
Passes
Conditionally Passes
Needs Fu 1131 the Local Aproving Authority
Fails
Inspector's Signature: Date:__
The System Inspector shall submit copy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY-
A)SYST PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system, upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes, nor,or not determined(Y,.N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
td broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
- l -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
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 the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A:MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The systemp absorption system
has a septic tank and soil abso tion stem and is less than 100 Feet but'50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. .. .
D)SYSTEM FAILS: .
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than G'below invert or available volume is less than 1/2
day flow.
•Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a 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 I 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. If the well has been analyzed'
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic.
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant .
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking water supply
The system is within 200Feet 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.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the-following have been done:
IrPumping information was requested of the owner,occupant,and Board of Health.
(.,'None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
_IZAs-built plans have been obtained and examined. Note if they are not available with N/A.
__&,Zthe facility or dwelling was inspected for signs of sewage back-up.
_ Z1`he system does not receive non-sanitary or industrial waste flow.
the site was inspected for signs of breakout.
_j,A11 system components,excluding the Soil Absorption System,have been located on site.
__,Phe septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees,material of construction,dimensions,depth of liquid_,
of sludge,depth of scum.
L,The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
_ZThe facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System ,
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION M
FLOW CONDITIONS
RF.. IDENTL4,Le
Design Flow:i 00 lions Number of Bedrooms:_ ts-
Number of Current Residen� g
Use-
Water
Connectcd'1'o S sl em: Seasonal
Garba a Grinder: Y
Water Meter Readings,ifavailable:
Last Date of Occupancy: &M 2
COMMF.RUAIANDUST IAL! V
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings, If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERA FORMATION
PUMPING RECORDS and source of inform,t' it: /�� C>� Q
System Pumped as part of inspection: If yes,volume pumped: gallons
Reason for pumping:
TYPE SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
-APPROXIMATE AGE of allSom T nents.date installed(if known)and source of information:
Sewage odors.detected when arriving at the site:
A
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: 1/
Depth below grade:— Material of Construction: /✓concrete metal FRP Other
(explain) —
Ditnisions i S-' Sludge Depth: 3 Scum Thickness: ,
Distance from top of sludge to bottom of outlet tee or baffle:_ 3�
Distance from bottom of scum to bottom of outlet tee or baffle: .fiewf-'
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation
on outlet invert,structural integrity,evidence of leakag etc. " I ell
7
f d ►� r� t'
�n
GREASE TRAP:�(�
Depth Below Grad : Material of Construction: concrete metal FRP. Other
(explain) — — — —
Dimensions: Scum Thickness:
Distance from top of scum to top 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,etc.)
TIGHT OR HOLDING TANK:
Depth.Below Grade: Material of Construction:_concrete_metal_FRP—Other(explain)
Dimensions: Capacity; gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert: /�Or!'AO
Comments: (note if level and distribution is ua1,evi ence of solids carryover,evidence of leal��geimo
or o t of box,et . ran ` j/
We
f
PUMP CHAMBER:
Pump is in working rder:
Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.)
A
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):
(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:
Leaching pits, number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields, number,dimensions:
Overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic failure level of pondin cg idition vegetation,
etc.) � -2CaS,� FI'd- � '7 r7 C. —er e
CESSPOOLS:
Number and oo guration: 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 soilk, signs of hydraulic failure, level of ponding,.condition of vegetation,
etc.)
PRIVY
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6_
wl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
ry
0
DEPTH TO GROUNDWATER: I
Depth to groundwater: Feet
Meth f be ermination or Approxima 'on: f� 47� Itil� ` /�O ail
e� r °&r e,4
-7-
_ i
f Date: z 9
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS:
BUSINESS LOCATION: T>0° ((9�MIA..�J �-f ii �.l L Aa4dht 914,
MAILINGADDRESS: A2 5464 e Mail To:
Board of Health
TELEPHONE NUMBER: `��47� � T�a Town of Barnstable
CONTACT PERSON: (' k A. �A VA�I
��' P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: S'r ��r✓( Hyannis, MA 02601
TYPEOFBUSINESS: 't w
Does your firm store arty of the toxic or hazardous materials listed below, either for sale or for you own
use? YES a/ NO
This form must be returned to the Board of Health regardless of ayes 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
Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid - Disinfectants M
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
:T--/O Paint brush cleaners (including chloroform, formaldehyde,
�- Floor & furniture strippers
117- Metal polishes hydrochloric acid, other acids)
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids ifs j Amm,�vu
(dry cleaners) Ig/o
Other cleaning solvents 1 0 Sd .ra
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
{
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FO.0 A^T I N SEWAGE PERMIT NO.s
3 t# G to 1-yI%Wf-4 6 i R C�,E
V-1L LAG E
INSTALLER'S NAME & ADDRESS
B U I L D E R OR OWNER
T
DATE PERMIT ISSUED ,^���.
DAT E COMPLIANCE ISSUED z if
c T '
-------------
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................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
t�wt✓......................OF......./��}l��!37 ...............................................
Appliration for Mipas al Works Tonstrnrtinn Prrmit r
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
w-!s..../!.ASS.
�1� Location-A dress Lot
............ ..................... ........................ ....... ....
Owner ► Address
W
Instiller Address
QType of Building Size Lot---------------_----------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage ,Grinder ( )
p, Other—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures
W Design Flow..._...............
...J................•-.-gallons per person per day. Total daily flow..............2210...................gallons.
WSeptic Tank—Liquid*capacity.!° ...gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area---y*.--......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--, ...........oss...A..l___________ _______ ..........
a
,.� Test Pit No. 1................minutes per inch Depth of Test Pit .................. Depth to ground water........... .........
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------------------ ....................................._...._.........•---------------------..........._..------------------.-----•-•--
0 Description of Soil.eo_4ns0,---s4-*?:...... �----...5%c•s! --••------•--------------------•----.......-•-------------...........----.......--•------•------
x
U ....................... --------------••--...•---.......------•---•----------.......------•---•-•---........-----•-----•••-••----•---•---•---••---------------•-•.....---.........-------••-•----•-•-•-•-
W -----•-•••----------------------..-•-------•----•------------•----------------------•-----------•-•--•--------••---------•-----------•---•-•-•--------•-----.....-----------•----•------•......------...
UNature 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 LIHIE 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 by e and o health.
-/d- 7Y
Signed �� .....- �•--------•----•-• ,
q Date
Application Approved By--.... f t...-----------------------••. -----------1//0"�..........
Date
Application Disapproved for the following reasons-----------------------•---------------------............._....------------------------......--•---••--•--•-•....
' -•--....-•-•---------------------•---•--....----......_..------------......------...------...------------.....----.....................................................................................
Permit No.......? ------------•------------------------ Issued..... 16p ......-- ..-----Date---.
Date
7
t �
No......................... Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�i.-, ✓ OF........f !�rr.��ra............................................ ....
Appliration for Disposal Works Tonstrnrtinn rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: Q
:<.� /r:1_'._...f:::... .. ....�!�......... G`r4.rv! %`..... r .. —�i`f= ` ....................................
.. ...
/1 Location-Address /'� 3 -.or Lot 1N�o. �/,,J
" f, -(r i C lJifi7� iu-,d `r/.r' _,l' /, /! .a..,r
.............................................. ..........___...._.........................................................................._.....
� Owner Addres
Installer Address
dType of Building Size Lot............................S feet
U Dwelling—No. of Bedrooms.__.........!=..............................Expansion Attic ( ) Garbage Grinder ( )
�4 Other—Type of Building No. of persons............................ Showers
YP g ---------------------------- P ( ) — Cafeteria ( )
Otherfixtures ----------------------------------------------------------•--.....••--••--•-•--•-•---•...-•------•---••--........--••---• ----------
W Design Flow.....` .... ...............................gallons per person per day. Total daily flow.................::°...................
WSeptic Tank—Liquid capacity..L�"_._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.... ���.c?[1.�........�' .__:' ...... .................. Date_..' .'
. ----_..._.
a Test Pit No. I................minutes per inch Depth of Test Pit _..._.._........Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x -------••---.........................................................
O Description of Soil..�'� � :__'__.._ r >- /) ' '' ` ' ' ;
x .----- ..........-••------••-•-•--••••-------•----•---•---•••---•--•••••-------------------•--.....--------.....---
U -----•...........-•-••...-••---••••--•------••------•-•-•-------•........................•---•--•-•-----..._-•-...•••-•-----•••------•••••---••----•••-•-••-----
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 TIT 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 by the board of health.
Signed...................................................................................... .&..................
Date
Application Approved By.......
... �_
................................................................••--------• - -
r Date w
Application'Disapproved for t reasons-----------------------------------------------------------------------------------------------------------•-••--
..............•-•............-----•---------••----.....-•-•---------••-•-•--••••------.......-------•--•-...........................................................•...................................
Date
Permit No........f_i.
----------------•-----------------•--- Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS `F
wt-ti�,y t}
BOARD OF HEALTH
- - }. Tatifiratr of Tompliaur _
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
y / .
Installer
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.......................... .................. da.ted_...... -__•-_-_-_._-_------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....................................................••--•-•---•-•••--•••-•----- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
e�..4,.. ........................OF.....1�!Jfl%�'..,`,%a>! �.
No......................... FEE........................
Disposal Works Tonstr ion ermi#
Permission is hereby granted_.._.=` ._ f .✓.! ..r_ .
to Construct `(Y ) or Repair ( ) an Ind/ivjidual Sewage Disposal System
at No.__-..t 7 f f a C ! r * +C
Street 7
jO
as shown on the application for Disposal Works Construction Permit No...... '_._..._.. Dated.......-____ ............................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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PME11-L INcr'
DATE : Dc� s , i7 Brvr.��sL� - lov7A5-S.
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221 *044Y /0a0/4-'T Ra
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ASSESSORS MAP : _*0/o TEST HOLE LOGS NOTES:
0 0-11 PARCEL:
FLOOD ZONE:
/ D ;��L/ '. SOIL EVALUATOR I I ,
_ _ WITNESS : 1 �.,�.,�J�. 1 1) The installation shall comply with Title V and Town of Barnstable Board of
REFERENCE: ��F�../ c�C -#27� `?I DATE. 1 Health Regulations.
PERCOLATION RATE: , 2) The installer shall verify the location of utilities, sewer inverts and septic
v components prior to installation and setting base elevations.
PC �� �' ��� '� �� 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first
jtwo feet out of the d-box to the leaching shall be level.S �V� 4) This plan is not to be utilized for property line determination nor any other
7
purpose other than the proposed system installation.
M.t 5) All septic components must meet Title V specifications.
tb 6) Parking shall not be constructed over H10 septic components.
-- �- --- � 7) The property is bounded b property comers and roe lines.
LOCATION MAP ' ,31'� yp p y property rty
�A ,6ml j 8) The property owner shall review design considerations to approve of total
II.Ai design flow and number of bedrooms to be considered for design. Receipt
of payment for the plan and installation based on the plan shall be deemed
approval of the design flow by the owner.
i 9) The existing leaching or cesspools shall be pumped and filled with material
2 5(� per Title V abandonment procedures. Those within the proposed SAS shall
_ _ Z be removed along with contaminated soil and replaced with clean sand per
Title V specs.
10)System components to be 10 feet from water line. Sewer lines crossing the
water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if
SEPTIC SYSTEM DESIGN applicable. The proposed SAS is being installed below the water service
line. The line is to be sleeved as aforementioned and maintained in place.
FLOW ESTIMATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the
owner to ensure such.
12)The installer is to take caution in excavation around the gas line if such
BEDROOMS AT ID- GAL/DAY/BEDROOM - GAL/DAY exists.
r _._ ` �.�' % «. _ °� '.-C' 13)The installer shall verify the location,quantity and elevation of the sewer
T I C TANK lines exiting the dwelling prior to the installation.
GAL/DAY x 2 DAYS GAL
USE 1000 GALLON SEPTIC TANK �(
SOIL AS OR P fi i ON SYSTEAT - _
it b S�A f.7
-
SIDE AREA: Z 2-,4 {- .l X 2X ��� = I ,JZ„ l t �3
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Z �� } r ,
-- LI) SEPT SYSTEM SECT I ON
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SITE AND SEWAGE PLAN
LOCATION : C1��
PREPARED FOR :
0
SCALE. 1111
W
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DAV I D B . MASON DATE: I Z �
Z DBC ENVIRONMENTAL DESIGNS
W DATE HEALTH AGENT
EAST SANDWICH . MA
Z ( 508 ) 833- 2177