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0105 FERNDOC STREET - Health
105 FERNDOC LANE, HYANNIS A=344-036 I �4 Y Hazardous Materials Inventory Sheet Checklist /V / Date r �— Physical Street Address-Check database to ensure it exists p -- Working Phone Number Actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials) Storage Information - location of storage,how long is storage for? If none, note that. Disposal Information -where and who? If none, note that. Applicant Signature - understand what is listed and noted ` Staff Initial -any questions, know who to ask ,, 14 Vehicle Washing/Rinsing? - provide a vehicle washing policy and --�+�—explain it-note that it was given Attach the Business Certificate with your sign off and comments *"The inventory form should explain what the business consists of and the procedures they are doing. t Pri to left to explain what you discussed with them. YOU WISH TO OPEN A BUSINES!OWN 0F A A For Your Information: Business certificates[cost.$40.00 for 4 years). A business certificate ONLY REGIST( °`Y© AME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necesgo s nat}}�Tres on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601�Ti� n Pi911)Nod)k5et3&ie Business Certificate that is required by law. DATE: Z' ' (} a Q in lease: ray , APPLICANT'S YOUR NAME/S: %.) ��7` �! �. BUSINESS. YOUR HOME ADDRESS: S[l TELEPHONE # Home Telephone Number a�?��;? /`,21 % 5 NAME OF CORPORATION:: NAME OF NEW BUSINESS , �` ;vGg/ TYPE QF'BUSINESS IS THIS A HOME OGCUPATION? YES NO 61, ADDRESS.OF.BUSINESS y�f �: w� �� MAP/PARCEL NUMBER �a y`. U. [Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. T. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual h n infor of h per "it etquiremgnts that pertain to this type of business. thorized Si -ture* T MUST COMPLY WITH ALL HAZARDOUS MATE COMMENTS: RIALS REGULATION$ 3. CONSUMER AFFAIRS(LICENSING AUTHORITY This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: TOWN OF BARNSTABLE Date: 7 TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: ) ,�- �' BUSINESS LOCATION: 1,0 S1-, Z�t INVENTORY , MAILING ADDRESS: �k x. xg-a-_ �1--T' 46 l TOTAL AMOUNT: TELEPHONE NUMBER: v� CONTACT PERSON: ;:y,- v EMERGENCY CONTACT TELEPHO NUMBER: Ef-lk- $'22 C>!3 MSDS ON SITE? TYPE OF BUSINESS: /L`L�1bt�L�.l�►�" C� rr��fY. 1� INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: &j /)o Last shipment of hazardous waste: Name of Hauler: W^52 . Destination: Waste Product: rrw-5 h► 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 �j Engine and radiator flushes Road salts (Halite) jj Hydraulic fluid (including brake fluid) /17 Refrigerants Q Motor Oils Pesticides ❑ NEW USED c) (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, v Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED �2 Degreasers for engines and metal © Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine 6 Battery acid (electrolyte)/Batteries v Lye or caustic soda J Rustproofers Miscellaneous Combustible 1(19 Car wash detergents <, Leather dyes 1�7 Car waxes and polishes « Fertilizers Asphalt& roofing tar c> PCB's % Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Othe roducts not liste- which you feel Floor&furniture strippers ay b toxicr haz ou>g lease list): Metal polishes Laundry soil &stain removers (including bleach) 0 Spot removers&cleaning fluids (dry cleaners) > Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials Hazardous Materials Inventory Sheet Checklist q LO Date Physical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts ( ie. gas being used to fuel machines,thinner to clean brushes all count as hazardous materials) !� Storage Information - location of storage, how long is storage for? If none, note that. Lam-- Disposal Information -where and who? If none, note that. Applicant Signature - understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? - provide a vehicle washing policy and explain it- note that it was given Attach the Business Certificate with your sign off and comments "The inventory form should explain what the business consists of and the procedures they are doina. Nntac naarl to he left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. rays , j *k , DATE:0 7A0 Y Fill in please: n� u a= r APPLICANT'S YOUR NAME/S: W7.),n c7 e y �' BUhSINESS YOUR HOME ADDRESS: 1.3 ar� 'h'y TELEPHONE # Home Telephone Number 7 N' NAME OF CORPORATION`:? vC (_. O /)h/C NAME OF.NEW BUSINESS TYPE OE BUSINESS ,R T y IS THIS A HOME OCCUPATIONS YES NO n. o S' :M 61 6�'i;'MAP' PAR.CE L NUMBER (Assessing) ADDRESS OF;`BUSINESS.f G. .. � a'r M <' When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in.obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual h en i fo oft epermit r uirements that pertain to this type of business. MUST CQMPLY WITH ALL Authorize Signature** HAM MIX MATERIALS REOMTK11IN$ COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: 1 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE ONVENTOR31 NAME OF BUSINESS: Pwd( Touch 4uto 1wc � �1 � BUSINESS LOCATION:(OS fP rnd- ©G Srt InA 63 G a I INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: 5b'8 gd-7 Y 63 CONTACT PERSON: EMERGENCY CONTACT TE EPHONE UMBER: 177 Y dog y/e/o MSDS ON SITE? TYPE OF BUSINESS:,4,-,t(-:, INFORMATION/RECOMMENDATIONS: Fire District: Waste Trans portation:,-YsT`,:) C' Last shipme�ifzardous waste: b� « /y Name of Hauler: Crk Tj-/ /cam Destination: y Waste Product: (L 0 Z Licensed? e-� No �[I j r17 y ©8 q0 NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED l� Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's v Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials Hazardous Materials Inventory Sheet Checklist 6� / Date Physical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts-(ie. gas being used to fuel machines,thinner to %'clean brushes all count as hazardous materials) Z/' Storage Information -location of storage, how long is storage for? i If..none, note that. if Disposal Information -where and who? If none, note that. 4 Applicant Signature - understand what is listed and noted Staff Initial -any questionsi know who to ask Vehicle Washing/Rinsing? -provide a vehicle washing policy and /explain it-note that it was given Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you,discussed with them. 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, 1st FL., 367 Main Street, Hyannis, MA 02601 (Tow H II). DATE: ► Q n' t u�,x � x Fill in please: flN _ r 'L APPLICANT'S YOUR NAME: .�V`I (UFO 11.E f�O ING ELl/V i✓ �,`x ,{,L BUSINESS YOUR HOME ADDRESS: au r11UH01" 4- Q2kV7 TELEPHON # Home Telephone Number: fZ n 3 y e5p!y NAME OF NEV1i' BUSINESS TYPE O..F..BUSINESS ,,:..... IS.A..H�,ME.OCCU,P.,ATI:t?N�!•'. - - !::: !! NO _. .. 1C S . :1 : ... .. .-. ..:: :. .... .. .. _.. ..v...: .. ADDRESS O US.F B :..::.IN15 .. : M,QPXP RCIL ..,. ! . NUMBER When starting a new business there are several things y u must do in order to be in compliance with the rules and regul tions 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 1. BUILDING CO MIS ONER'S OFFICE Lkr)1 This individual q..n i o d fa y permit requirements that pertain to this type of business. \\ Aut orize¢_.Signa e** COMMENTS: 2. BOA OF HEALTH This individual been it orm d of t e.per t requirements that pertain to this type of business. Authorize Signature** MUST COMPLY WITH ALL COMMENTS: /1/0 eewr-o Ids- ),ire j9WQIAMATERIALSREGULATIONIS /� D'Tk L��'T' Ili GLN IT iL ViJE"7GGr GU1/R. 3. CONSUMER AFFAIRS (LICENSNne G AUTHORITY), COP This individual has I n infjbryc�g .f the licensing requirements that pertain to this type of business. ut zedSignature*** n COMMENTS: (�lJ � r / �Q TOWN OF BARNSTABLE Date: �r// TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: \r - Wro SA� BUSINESS LOCATION: JOJ 1� INVENT O Y MAILING ADDRESS: Afilw(4 jW TOTAL OUNT: TELEPHONE NUMBER: g CONTACT PERSON: -zSkj�[ 0O !u wD EMERGENCY CONTACT TELEPHONE NUMBER: 508- 31Co 36G"4- MS S ON SITE? TYPE OF BUSINESS: GAL MXLA2 INFORMATION/RECOMMENDATIONS: R()S_( NESS U9J'C6-- CAI " Fire District: ILS �)n op ,ice Oio& 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 Other chlorinated hydrocarbons, 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) df 1 � �' frA�a Other cleaning solvents Bug and tar removers V/ Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: Iv) s Cdk s ti BUSINESS LOCATION: /621 �A INVENTORY MAILING ADDRESS: SA"o e �aL-a TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: //7101 icjo9Aeur EMERGENCY CONTACT TELEPHONE NUMBER: 129k 6E!i__ 1�?/,' MSDS ON SITE? TYPE OF BUSINESS: J 'yy�cie Z� INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: 1 Z 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) 2 Misc. Corrosive �w� CD AEI",1. Co Cesspool cleaners s Automatic transmission fluid d Disinfectants :Y/HOydraulic ) ine and radiator flushes Road Salts (Halite) fluid (including brake fluid) Refrigerants S"�to or Oils —_ �2 Pesticides _,�-KNEW 6- USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) C)Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED d Degreasers for engines and metal Printing ink Degreasers for driveways &garages Q Wood preservatives (creosote) d 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 Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED CJ Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) 0 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) Other cleaning solvents q � and tar removers 'Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS I'azarr+ous Materials Inventory Sheet GnecKust a p Date P ysical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts-(ie.gas being used to fuel machines,thinner to clean brushes all count as hazardous materials) —1--�torage Information-location of storage,how long is storage for? If none,note that. 4--l7fisposal Information-where and who?If none,note that. Applicant Signature-understand what is listed and noted Staff Initial-any questions,know who to ask Vehicle Washing/Rinsing? -provide a vehicle washing policy and m it-note that it was given Attach the Business Certificate with your sign off and comments "The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? FForur Information: Business certificates (cost$3.0.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town which st do by M.G.L.-it doesnot give you permission•to operate.) Business Certificates are available at the Town Clerk's Office, 1° FL.(367 treet, Hyannis, MA 02601 (Town Hall) �ni:.A .ta:sxwa ttcpyp uC:48B '"'s'"" 0.4 OF S" IN WE . �p.� Fill in please: - A APPLICANTS YOUR NAME: t A �A 1gUCINE99 YOUR HOME ADD ESS: t r TELEPHON Home Telephon umber - Imo.. —17-76 NAME OF NEW BU�IiVES'S �Z fl }I W6 TYPE OF B.i1SINE5S Y '�, _: I5 THIS A OME OCCUPATION? YES NO ., r�' e a Teo ►vlslo: ,...: - ADDRESS OF BUSIIVES5 f1 - MAP/PARCEL NUMBER vd&&:�f �, When starting a new business there are several things you must do in order.to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you y fray need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. &Main Street).to make sure you have the appropriate permits and licenses required to legally operate^yduJ_r_b_us`i_n_e`s`sln this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed-of any permit requirements that pertain to,this type of business. Authorized Signature** .COMMENTS: .2. BOARD OF HEALTH This individual ha!s2ppp infor e p r it requic ents that pertain to this type of business. Authorized S• ature** LEWCOMPLYMA11 COMMENTS: . HAZARDOUS MATERIAL$REGULATIONS 3• CONSUMER AFFAIR LICENSING AUTHORITY This individual hC� n in or a Uf e lice s g r q it etas that pertain to this type of business. Authorized Signature.* COMMENTS: �i t'. Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: INVENTORY MAILING ADDRESS: D 4BO, 'o(— IL71 1,h4am('SPbd- d'2p9— d TOTAL AMOUNT: TELEPHONE NUMBER: Sc CONTACTPERSON: EMERGENCY CONTAC TELEPHONE MBER: fq4v ..464 77l/7GgMSDS ON SITE? TYPE OF BUSINESS: cam✓ Va S 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) —Omisc. Corrosive 0`� e NEW �JSED dCesspool cleaners � Automatic transmission fluid Disinfectants Engine and radiator flushes C-1 Road Salts (Halite) 12- Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW O USED (insecticides, herbicides, rodenticides) V Gasoline, Jet fuel, Aviation gas Photonchemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil U JNEW C= SED 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 t9 Lye or caustic soda Rustproofers 1 Misc. Combustible Car wash detergents Leather dyes tQ i Car waxes and polishes Q Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, D Lacquer thinners (inc. carbon tetrachloride) 0 NEW 0 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 paybe to is or hazardous (please list): Laundry soil & stain removers__ (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: TOWN OF BARNSTABLE , TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: Q-� C S \ S ` BUSINESS LOCATION: y INVENTORY MAILING ADDRESS: ^� —� � TOTAL AMOUNT: TELEPHONE NUMBER: CA, rl\C\ CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: pSk MSDS ON SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: Fire District: 1 I 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 j 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 fuef, 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 Other chlorinated hydrocarbons, 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) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS I David B. Mason, RS 0 December 13, 2002 Mr. James Burke a Burke Homes Company 1 Thornton Drive Barnstable, MA RE: Sewage Flow Calculations, 105 Ferndoc Road, Hyannis, MA Dear Mr. Burke, At your request this office has reviewed the capacity of an existing Title V septic system that services four units at the referenced address. The objective is to determine the allotted sewage use and available capacity of the existing system. This office obtained the following records; Septic As-Built Plan (permit#83- 464),Application for Disposal Works Construction Permit (permit#83-464), the Site and Sewage Plan prepared by C.R. Short, PE dated June 8, 1983 with a revision date of August 23, 1983. The septic system consists of a 1000 gallon septic tank, a distribution box and two flow diffusers with 3 feet of stone around. The plan and as-built on file indicates that the flows are connected together, but based on an inspection conducted by Jim LeBoeuf Septic Service, there are two flow diffusers installed separately with 3 feet of stone around each. For the purpose of calculating the flows this office has based those calculations on the installed scenario as identified by Mr. LeBoeuf. I The total calculated capacity of the aforementioned leaching system is 520 gallons per day. This is calculated on the original design basis of the 1977 Title V acceptance rate (gallons per day per square foot). 4 Glacier Path, East Sandwich, MA 02537 508-833-2177 � David B. Mason, RS With these known facts and the records reviewed, the following flow (gallons per day) has been calculated with the 1995 Minimum Allowable Gallonge per Day Flow Design Criteria. Square Footage Use Flow per Title V Total Flow 4000 Square Feet Baseball Cages 10gpd//person w/ 20people 200gpd 2000 Sq. Ft. Warehouse Factory 15gpd/person 30 gpd 4000 Sq. Ft. Warehouse Factory 15gpd/person 30gpd Total Gallonage per Day 260 gpd Available Capacity 260 gpd The remaining unit is a 6000 Sq. Ft. unit that has the availability of 260 gallons per day. Problems due to incorrect calculations or available septic capacity is not the responsibility of this office since these calculations may be subject to change on the basis of changing uses, increase in septic flows due to unknown future changes, lack of information not made available to this office and the assumptions that must be made for the type of septic installation or that such was installed correctly. Respectfully Submitted, 1 David B..Mason, RS 4 Glacier Path, East Sandwich, MA 02537 508-833-2177 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 mustdo by M:G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerks Office 1 FL. 367 Main Street Hyannis, MA 02 601 (Tow H II}. DATE: ► D { i yr ,xak Fill in please: APPLICANT'S YOUR NAME: BUSINESS .Y/1/O�U/�R HOME ADDRESS: /� A TELEPHON # Home Telephone Number: _ 53 5RV NAME OF hIEW(BUSINESS..: ' I I 1 1 � A;E OF BUSINESS IS THIS'A HOME,OCCUPATIOM? 1FES .Have ou:beeh . ve No ! . ... .! : : � M��r�aacEl NUMBeR � �`;� •I When starting a new business there are several things y u must do in order to be in compliance with the rules and regul tions of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO MIS ONER'S OFFICE Lkrl 1 - This indivi ,ual erefl ijQn d f a y permit requirements that pertain to this type of business. 11 Aut orizeO-Signa e** COMMENTS: i -' u� 2. BOA9 OF HEALTH This individual been i orm d of t e�per 't requirements that pertain to this type of business. Authorize Signature** ` '` MUST COMPLY WITH ALL COMMENTS: "AZARDOUS MATERIALS REGULATIONS 3. CONSUMER AFFAIRS (LICENS/ING AUTHORITY) This individual has n inf ryno ( the licensing requ.irements that pertain to this type of business. COMMENTS:_ iU=ze E � C � - ` TOWN OF BARNSTABLE C G €.. ",..` LOCATION cwti 00C. SEWAGE # aI7 _ 7 VILLAGE ASSESSOR'S MAP & LOT 3 4+--� INSTALLER'S NAME&PHONE N0,-2e9 SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type) 3 A6'eYW G�/S S* X 9 (size) 3 ep X NO.OF BEDROOMS BUILDER OR OWNER I�A /4e"� Av4 I r c- PERMITDATE: .3 e3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by p� h Th TOWN OF BARNSTABLE o C LOCATION SEWAGE# / VILLAGE Y� ✓iv r'S ASSESSOR'S MAP &LOT Xy03t INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY C S LEACHING FACILITY: (type)SX lit`/Lead' �lS (size) NO.OF BEDROOMS BUILDER OR OWNER �/� �' ✓u L= PERM TDATE: J —��c� �� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � C a r � a � 1. No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for 3Di.5po!5a[ *"tie Con.5truction i3ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. �'e' 2 oo, siQE T PA5.rvz ie.9 Assessor'sMap/Parcel Sr '144A,, _ ..,�w�ivY Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /-7/2G/V 77s / 36a Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil N 5e of Repairs or Alterations(Answer when applicable)) L/ .P G 4,0 Dee /c7 / ?'1' l/ �5 s®® cv-,q A--A' Cst/s7>9// /Sab,5T (3 j Spa 6G,o Date last inspected: S>•✓Fr �` RFgg 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 t to place the system in operation until a Certifi- cate of Compliance has been issued y this and of U91th. S i g n e Date / 30 9 Application Approved by 1.4 A«R Date o �' Application Disapproved for the Milowin,g reasons Permit No. Date Issued G No. Fee �Z THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Mopo$al *proem (�Conmruction Permit t Application for a Permit to Construct( )Repair Grade(;-)Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. f 5- �e R nvJ), DG Si Q E L T P,q?at ,C,4 de"?I,- Assessor's Map/Parcel 36 /6100 0 LA,,,7 2e./ Installer's Name;Address,and Tel.No. Designer's Name,Address and Tel.No. ,A 12 G/•I Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) a Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when appli able) '[/ G 1? X144E To 71 7-/cp r3) .So0 GSA-e-Al 't'STo�.� Slued(ram/ LSV 0c s C/w eft dc-rs 4,-'f7.0 -C X02 ly.�$/� 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 t to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of He h. ory Signe Date 30 Ar Application Approved by Date 2 Application Disapproved for the Hlowinj reasons Z Permit No. 62 12 Date Issued t _ ----- ---------------------=--=-----=-- - - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (compliance THIS IS TO CERTIFY, that the On-site;Sewage Disposal System Constructed( )Repaired( ),Upgraded( ) Abandoned( )by 7- at D c)e-- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date_ '1 `X _ 9 ;? Inspector Cj No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigogal *p.5tem Con5truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( Abandon( ) System located at / d 5- /Sr/t,✓ c S-T n F i T 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. Date: - DO Approved by t I QN/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I,�UG yy� �2��r„ryi3�A� hereby certify that the application for disposal works construction permit signed by me dated 4 ,concerning the �� property located at 5 'Pr ;' meets all of the foll owing g win criteria: There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system a There is no increase in now and/or change in use proposed • There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will DDI be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) 6 SIGNE DATE: f LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER s [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cart ca 1 i �k d C3),soo //L-yrA30X �i ovsi 4` f �TME Town of Barnstable � Department of Health, Safety, and Environmental Services • wtxffreaLe, � Public Health Division i639• �� P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health January 30, 1998 Patricia Burke 36 Moonpenny Lane Centerville, MA 02632 Dear Ms. Burke: ORDER TO COMPLY WITH 310 CMR 15 00, STATE ENVIRONMENTAL CODE TITLE V AND ORDER TO REMOVE ILLEGAL SEPTIC SYSTEM On January 29, 1998, Health Inspector Jerome Dunning observed an individual who was installing an illegal septic system at 105 Ferndoc Lane, Hyannis Massachusetts. That individual did not possess a valid license to install any septic systems in the Town of Barnstable. In addition, the system was being installed without a valid disposal works construction permit. You are ordered to remove the illegal septic system from the ground on or before February 4, 1998. You are also ordered to hire a licensed disposal works installer to install an onsite sewage disposal system at 105 Ferndoc Lane Hyannis Massachusetts on or before February 10, 1998. You may also request a hearing before the Board of Health if written petition requesting same is received by the Board within seven days. Also, any person aggrieved by an order may seek review pursuant to 310 CMR 15.421 or 15.422. Each day's failure to comply with an order shall constitute a separate offense and may result in penalties. PER ORDER OF THE BOARD OF HEALTH. T omas A. McKean Director of Public Health 1 f PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 344 036- - Account No: 250221 Parent : Location: 105 FERNDOC ST Neighborhood: HY17 Fire Dist : HY Devel Lot : Lot Size : 2 .40 Acres Current Own: BURKE, PATRICIA M State .Class : 401 36 MOONPENNY LANE No. Bldgs : 1 Area: Year Added: CENTERVILLE MA 2632 Deed Date : 100194 Reference : 9400/001 January 1st : BURKE, PATRICIA M Deed MMDD: 1094 Deed Ref : 9400/001 Comments : Values : Land: 195400 Buildings : 519500 Extra Features : Road System: 105 Index: 530 (FERNDOC STREET ) Frntg: 200 Index: 150 (BODICK ROAD ) Frntg: 40 Control Info: Last Auto Upd: 072295 Status : C Last TACS Update : 063095 Land Reviewed By: Date: 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : 1075 Taken: 101190 Account Status : PO Hold Status : PO Cancel [ ] Press XMT for more data Next screen [QAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [344] [038] [ ] [ ] [ ] a>. TOWN OF BARNSTABLE C c LOCATION I CAS f'C/Z n/Do G SEWAGE# � VILLAGE S ASSESSOR'S MAP& LOT ivy INSTALLER'S NAME&PHONE NO./92,C,11 e'o' ,vST ,. .:SEPTIC TANK CAPACITY S o Cr-4 LEACHING mcmrrY: (type))-5—X r l�?`/Guy' S (size) .".,.NO..OF BEDROOMS � /a?f? iciA�:'BUIl,DER OR OWNER �u lI fr E' pERMTrDATE: COMPLIANCE DATE: a, • _�'.— �� ::Separation Distance Between the: ::.:Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet >>Ptivate Water Supply Well and Leaching Facility (If any wells exist on site of 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 w Q Td30 ,no sbood(1t91 HD TOWN OF BARNSTABLE Ca. C 0 LOCATION SEWAGE # - 4 VILLAGE ASSESSOR'S MAP&LOT 3 INSTALLER'S NAME&PHONE NOf 9 c N ••,�S 'SEPTIC TANK CAPACITY /S o D GA , LEACHING FACILITY: (type) 3 AV /a, (size) .3 O X/.:4 Y' � -OF BEDROOMS :. BUII,DER OR OWNER A %1A&A 9&,4 /-r C ::.PERMTTDATE://3 � COMPLIANCE DATE:____3`_� ::.Separation Distance Between the: :1Vlaximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet >::;Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet .''Furnished by 1 4 .. . ' .... 9 fro�0 :s x X_ X. X ��s�i✓S'ri� ;;y� 1� 9.9N'Nv000 3� /7/4 Y Nta: �_. '•........---- 4THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH W/../...........OF....... ............. !fir Appliratijan for Uiipn. al arks Cnnnstrnrtiun Prrmit Application is hereby made for a Permit to Construct (v'jor Repair ( ) an Individual Sewage Disposal System at: /nx..co Z ®............ .. .. --.... ..,,. `..... ............................................................ ... .... ... ... Location-Address or DI?bs� ! �°71 av _ �ii TT?!t� �@ - No. am .............. Owner Address W ,-1 •......................................•-•-•-----•-----......_..--------•-------•-•------------•-- ---•----•-------------....._..--•-••--------......._..---......_.y..........._..... Installer Address . Type of Building `' Size Lot_/P-r Z .....Sq. feet U Dwelling No. of Bedrooms............................................Ex Expansion Attic� g— p ( ) Garbage Grinder ( ) aOther---Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther,,fixtures ........ ...............•-•--•-----------•-••------•--......-----••-•--•--•---•--•--•-------------._.....-----------------...-----•----........------. W Design Flow_ ..............gallons per person per day. Total daily flow--- ��`____................gallons. WSeptic Tank iquid capacity./P�__gallons Length......:......... Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width................... Total Length__W/'-._Z'n�_ Total leaching area....................sq. ft. Seepage Pit No........-a'............ Diameter....../.l,�_........ Depth below inlet...... ..... Total leaching area..... �Z...sq. ft. Z Other Distribution box ( ) Dosing tank ( _ ~' Percolation Test Results Performed b ..._.'-_................................................................... Date..---_. _... � Test Pit No. 1 Ln..� ._minutes per inch Depth of Test Pit------!!�........ Depth to ground water........ ............. 44 Test Pit No. 2_!!�-.�..minutes per inch Depth of Test Pit...... ----- Depth Depth to ground water........................ Ix ----•---------------------•----------•----------...-•--••------......----•-•----.. ---......................................................... -- 'O Description of Soil---� =-3e ��'---------•310 & 4:! .' • ✓ash �4 ....:9'1' 7 x �4'.....`....,�_`.' :�_..��_--=5-�/J�----•----------- ----•-•----•-------•--••----------- v 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 LITL p 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. gne _..----••................•--------.....-----.._........------•--••----------- .- ...._.... Application Approved By. Date Application Disapproved f th ollowing reasons:----•-•-•••----•-----•••---••-•-----••••••-----•••••-•----•--•••-•-•-•---•-----•••--------------•-••-•---_...._ ....................•---......---•-----•-----------------•----------•------••----•----.......--------•---------•----•--------•------------•------••-•-------------•••••--------•••••---•-----•------_... Date PermitNo. .. ... Issued..................................................7..... Date fl Fps...: `©r............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........Tln/�............OF...... Appliratiou for Disposal Works Toustratrtion thrmit Application is hereby made for a Permit to Construct (vll"or Repair ( ) an Individual Sewage Disposal System at: Ok F BOD/(±LC ..r>. /� A?�.v..5.........-•........ ............ •-Z�Z._...PG_f�'Z- .......-•-------......... ...............-_----•• •-•...._.-••---- Location-Address or Lot No. 8u/t-AG6 /jns-s46- C4 W.?/ ?v�/ �..-Tt/.a Z-,7&-_' 1�!�:.....�RY?�!ST/��r��.` ... --..... -----•--------- - --- ... ... Owner Address W Installer Address Type of Building Size Lot./as�5:3.....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures .----------•-•------------------ --- W Design Flow gallons per person per day. Total daily flow---..........G �..._................gallons. WSeptic Tanki'a-, iquid capacity.l4p�?..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length........Z....... Total leaching area............--------sq. ft. Seepage Pit No......3........... Diameter......lo:.------- Depth below inlet-..._.At ..... Total leaching area...-��.'`�...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '•' Percolation Test Results Performed by ...e.S�- T .......................... Date.�LL!�- S1-%Ra L Z, . ....... o ---... Test Pit No. 1................minutes per inch Depth of Test Pit......11............ Depth to ground water..............._.-.------ (i, Test Pit No. 2_: :_ ...minutes per inch Depth of Test Pit.....!Z�_��-_ Depth to ground water........................ Q'+ ----------....... ------------------------------------------------- -------------------.--------------------------•----..... --------•-....... ---------- D Description of Soil...o .�. .../ 4-4, ` 3c, 7e w •----•.................... ". C � ' . % 7z. '` � G"x cGc . ..r...=•--s'`.°-' -••-.....----•••-------•--•-----•-------•-------••------•-•.............................•--------------. 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 L, 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. gne --••-•....----•----••-......--'-......•---•-....--•-------------------••-....--- Application Approved ByIth - --- -----------------------••-----------•.....-----------------..........--- =r r S`� J Date ----------- Application Disapproved following reasons:---------•----------------------•-----------------------------•-------------•----------••-••---------••----'"-- ...........................'---•---'--•----------•--•-----•-•.............•--'-•-•-....---...-•••--....--••--------•---------•---•-'---•----•---------------------------------------•-----•••--•--'---" Date PermitNo......................................................... Issued....................................................... Date .oe"I" THE COMMONWEALTH OF MASSACHUSETTS D . BOARD OF HEALTH Tb.LV!v............OF....... ... - ............................... fit wrtif iratr of ToutpliFam THI IS TO =ERTIFY, That the Individual Sewage Disposal System constructed or Repaired F g P �' ( P ( ) Installer ::...... v� at........... ..... V --------•--•------------------ has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Cod s d cribed in the application for Disposal Works Construction Permit No... --.--...... dated-.4_ .. Q-.-. �................... THE ISSUANCE O THIS CERTIFICATE SHALL NOT BE CONST E® AS A GUAR NTEE THAT THE SYSTEM lNIL UN ION SATISFACTORY. DATE-----..//.---�3-----•-- •--•-'-•-"------------------------------------ Inspector -------------_--•------••----------•-------------•---------••------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /...........OF........ i —S%i13LE"............................ Q Nd............... ...... FEE...141................ ._ - �i��r�a��l �r ���aat�trttrtUan rrmit Permission ' her y anted '-_=G..... ...01='' ' `= to Construct R it ndividual Sewage Disposal System at No.- .......:........... ------------ -----• --•- Street as shown on the application for Disposal Works Construction Permit N/.. Dated.....•......................._............ -------•-.. ---------------------------------------'-----...DATE..L/. Z? -- ---- Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - Sty`_.. ^` !lr_-"�1::y..u. ,. 3--� �� a t Permit Number: Date: Completed; by : HIGH GROUND-WATER LEVEL COMPUTATION Si te`Locat ion: L_ 5/c Z` Z C�, $ Z Lot No. Owner: Address: ,Contra=tor: Address: Notes: o fit=— 13 � 2=�, c-K' 2 �_ �L/ �✓� e STEP 1 Measure depth to water table 7 ., to nearest 1/10 ft. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .4/S/6 3 e date S. 93 STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A) Appropriate index well . . . _. . . . B) Water-level range zone STEP - 3 Using monthly report"Current - Water Resources Conditions" determine-current depth to Z1,3 water level for index well / 83 . mo yr STEP 4 Using Table of Water-level Adjustments for index well STEP 2AI, current Apth. to water level for index well , (STEP 3) , and water-level x zone (STEP 2B) determine ©. water-level adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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