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HomeMy WebLinkAbout0039 GEORGE STREET - Health 39 George Street `. Hyannis, NIA .02601 - - 0 j i °o �; o YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you .permission to operate.) Business Certificates are available at the Town t Clerk's Office, 1' FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and 200 Main Street Offices at the.Licensing counter. DATE: Z O Fill in please: 'r APPLICANT'S YOUR NAME: h BU IN SS YOUR HOME ADDRESS` _ V GC-'o2 fit= C,q ......., 77 7�©77 TELEPHONE # Home Telephone Number: 7Z - '(67 - .7 NAME OF NEW BUSINESS �►`�"i��i ,�qi/v i�I/ ,TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES NO Have you been given approval from the building division? YES NO ADDRESS OF BUSINESS 3c —002� �' �3 /' ' MAP/PARCEL NUMBER When starting a new business there .are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to .assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1 . BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements'that pertain to this type of business. Authorized Signature COMMENTS: 2. BOARD OF HEALTH This individual h been inf of der it requirements that pertain to this type of business. Authorized ignature** MUST I�OMPl.YVVITHALL COMMENTS: N&Ao QU$MWERI MIM71ONg 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. t Authorized Signature COMMENTS: Date: 12$/ Ot TOWN OF BARNSTABLE , TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: CACT.eflncc- ;:/9 lI '?OAlr& BUSINESS LOCATION: 3 9 CE iI5O/zr� ��� y�y��°`� INVENTORY MAILING ADDRESS: �De y/v/ ks TOTAL AMOUNT: TELEPHONE NUMBER: 7 ZZI 4/87 �677 eN CONTACT PERSON: C-'«®A./ EMERGENCY CONTACT TELEPHONE NUMBER: 774 487 /0 7<7 MSDS ON SITE? ,(- TYPE OF BUSINESS: ,-941)-Al!�E' 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 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 Lv{ l( 9 \'v� may be toxic or hazardous (please list): Laundry soil & stain removers ' c �—rloe�' P9/A/7'1 AlIc (including bleach) T© 7-(c ��5 7711,r-vr Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers zS`� Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Commonwealth of Massachusetts 1.0't`H Ur BARNS1��BLE /i30s Title 5 Official Inspec_jLg.g FoPR Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on th6l otfMIJTitle 5 Inspection Form dated 611512000.Inspection forms may not be altered in any way. A. Certification Important When filling out 1. Property Information: comps on the computer,use 3�S7e©�, e S4- -"Y A•A)Ly PS (Ift,9( o a►�o01 only the tab key Property Address to move your �ay MX—%V � use the return cursor-do not Owners Name key. Owners Address Citylrown state Z'Q.Pode Date of Inspection: Date 2. Inspector Name of In _ F- Co �5 IBv zz.A-ems 8� 1��• .. co ny Address V M4 a AA d a 3 a City/Townt, Q n State Zip Code Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and c6Mpl6te.at.of the time of the inspection.The inspection was performed based on my training and experience in tM.proper function and maintenance of on site sewage disposal systems.I am a DEP appfoved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: E P sses ❑ Conditionally Passes ❑ Fails ❑ Needs Further uatio the Local Approving Authority Inspectors Signature date The system inspector shall submit a copy.of this inspection.report to the Approving Authority(Board of Health or DEP)within 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 DEP:The original should be sent to the system 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. t5insp.doc•11/2004 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System -. ............. .......- - _.. . . . .... - ... ...._....._..-...__... _--Pagelof16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 3 9 Property Address v h2dUk mA - City/To State Zip Code -AN Owner's Na Date of Inspection 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 ariy 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: B) System Conditionally Passes: /.� ❑ One or more system components as described in:fhb"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. Answer yes, no or not determined(Y, N,ND)in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old'.or the septic tank(whether metal or not)i,s 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 if 6'struclutally sound, not leaking and if a Certificate of Compliance indicating that the tank it.less;than.Z6 years old is available. NO Explain: t5insp.doc•11r2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cant.) '3a C7eor4C, S-�. PrirVis MA 14jityrilD D a SS State/ O�i Zip Code Owners Nhme Date of Inspection B) System Conditionally Passes(cont.): AW ❑ 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: NC) Further Evaluation is Required by the Board of Health: El 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 surfaco water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5insp.doc•1U2004 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title .5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Foi m: A. Certification (cont) 3g (TcoreR . Pr a ddr�ssf i s MA O O I R M Az SS State � ' aU'b 5 Zip Code. Owner's Name Date of inspection C) Further Evaluation Is Required by the Board of Health(cont.) 10 2. System will fail unless the Board of Health Land 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 acid 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 and volatile organic compounds indicates that the well is free from pollution from that facility 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: t5insp.doc•1112004 Title.5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) rqe Prop*tyILLA � [5 M,A o 4 o Ci�/To w� State I � ZipCode Owners s N7ame J Date off Inspection 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'/day flow ❑ 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. D 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 coliform bacteria and volatile organic compounds indicates that the well is free froth pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than.5 ppm, provided that my other failure criteria are triggered.A copy of the analysis must be attached to this form.) Yes No El The system fails: 1 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 failut€.. . . t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts" Title 5 Official Inspection Form. Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont. 3q Geror e , a#- AijmLS A►kA caW C#YrTPA N State � 1�_fl Zip Code Owners Name pate of Inspection. E) Large Systems: To be considered a large system:the system must serve a facility with a N design flow of 10,000 gpd to 1.5,000 gpd. For large systems,you'must indicate either`yes°of ane-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 nitrogeti:sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II'of a.public water supply well If you have answered"yee to any question in Section E�-the system is considered a significant threat, or answered`yes'in Section D above the large system figs.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 CUR 15.304.The system owner should contact the appropriate regional office of the Department. t5insp.doc•1112004 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System. Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 3g S� Proertyva&ts NIA oa�,o Cdyrr wn w D MASS State �/all ^�� Zip Code Owner's Name Date of Inspection Check if the following have been done.You must in '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? I ❑ 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? ❑ Was 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 exmpie, 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(3)(b)J t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 3 4 CTe�o r e �E . P erty Add re N�>h o ab a l State 5�a� _�S Zip Dods Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes VNo Is laundry on a separate sewage system?[if yes.separate inspection required] ❑ Yes U/No Laundry system inspected? /✓A- ❑ Yes ❑ No Seasonal use? ❑ Yes VNo Water meter readings,if available(last 2 years usage(gpd)): Sump pump? ❑ Yes 5KNo Last date of occupancy: uPi,e. Date Nr \ Commerciallindustrial 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 Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp.doc•11/2004 Ule 5 Of:c'W.lnspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary,Assessments Subsurface Sewage Disposal System Form C. System Information Cont.) 3°I G eo e `t PAd `� �s MA '� _ ba o YR wn �� States. a$ o� Zip Code Mr - Owner's Name Date of Inspection General information Pumping Records: Source of information: �(2e�u Q Lg-) Was system pumped as part of the inspection? ❑ Yes Ve"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 yds,- 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) ❑ Tight tank.Attach a copy of the DEp a6proval. ❑ Other(describe): Approximate age of allc mponents, date installed(if known)and source of information: -Y Were sewage odors detected when arriving at the site?. ❑ Yes No t5insp.doc•11r2004 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official .Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 3gCTexrQe, S-E � yP�Qpe AddfelV I S 1'l� O:k S D I r IV State 5 a� os Zip Code Owners Name :°Date of Inspection Building Sewer(locate.on site plan): �^ Depth below grade: feet Material of construction: ❑cast iron W"4'0 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): to C) -t y t eauc-e o To L i S 1S4,j c. %.,,,,-((�A.4 �Septie-Topk.(locate on site plan): 3 , Depth below grade: feet Material of construction: concrete ❑metal ❑fiberglass 0 polyethylene ❑other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach:a copy of ❑ Vf o certificate) Yes Dimensions: I X © A Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness N A Q<< Distance from top of scum to top of outlet tee or baffle ti A- Distance from bottom of scum to bottom of outlet tee or baffle ✓� How were dimensions determined? 51 C t5insp:doc•1 U2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) Probetty fldldl��Sv C� rr wn State Zip Code KOM MASS 5-ag --Os Ownei's Name Date of Inspedion Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liqui lev Is as related to o tlet invert,evidence of leakage.etc.): Al _ L�t Lo A; .Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑tibefgtass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee orbaftle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): N �. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grader Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): t5insp.doc•112004 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Rim 110 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information nt.) 3q Geor S . MZIS MA oa�ol ty own State Zip Code b� MASS Owners Name 'Date'of Inspection N ,A Tight orHolding'Tank(cont.) f1►T Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in Working order. ❑ Yes❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): NA\ Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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,): ,� ) f�. Pump Chamber(locate on site plan): '�/�' ` Pumps in working order: ❑ Yes ❑ No Alarms in working order: El Yes ❑ No t5insp.doc•112004 Title 5 Official Inspection Forth:Subsurface Sewage wage Disposal System- Page 12 of 16 Commonwealth of Massachusetts Title, 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Fora C. System Information (cont.) Pr erty�t�t�tS �► M� o a�o I State• -. Zip Code � r- Owners.Name Date of Inspection Comments(note condition of pump chamber, conditio'n.of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If.SAS not located,explain why: Type: leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number. ❑. leaching trenches number, length: ❑ leaching fields number,dimensions: 61 overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic.failure,level of ponding,damp soil,condition of vegetation,etc.): t N ay �2 �4 o u — NO t, t5insp.doc•11/2004 Tit1e,5 0ffaal Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Informatio (cunt.) 3q Ga t- e St pert s M� _ 6 alb Zip Code Owners Name Date of Inspection �) Cesspools(cesspool must be pumped as-pait of inspection)(locate on site plan): /V 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 Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Privy(locate on site'plan): Y� Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc•11I20O4 Title 5.Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection dorm Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. S stem Information (cont.) 3� C-�r � St . MN o ado I %Ag p ,'V�t c� state 5-a8 Zip Code J --os Owners.Name :Date of Inspection. Sketch Of Sewage Disposal System: Provide.a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. C pry, m t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 v Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. S stem Informatippn (cont.) 3� GeoreSt , WopeA nP is MA o a o l row, State,',g _Q, Zip Code Owner's Name Date of Inspection Site Exam: Slope. Surface water ✓'Check cellar Shallow wells Estimated depth to ground water. 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 !served site abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health explain: ❑ Checked with local excavators,installers--:(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: n l.� S _-9 A- Le c t5insp.doc•11/2004 Title 5 Official.Inspection Fomc Subsurface Sewage Disposal System- Page 16 of 16 TOWN OF BARNSTABLE LOCATION 3 SEWAGE # VILLAGP- i4-AY-VLS ASSESSOR'S MAP & LOT V INSTALLER'S NAME&PHONE NO. ! QK, �'e 'FQI������ SEPTIC TANK CAPACITY PC+ cCivQ-t)�UU LEACHING FACILITY: (type) �����;4 (size) 6 X NO.OF BEDROOMS 3 BUILDER OR OWNER s6*- 1Dr�Q CA-SS1Dt�Q CR-S- s PERMIT DATE:UN KeO� COMPLIANCE DATE: X O 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 leachi li� �Feet Furnished by�Tr� I _ r I.a►.. H ar s Materials Inventory Sheet Checklist to Physical Street Address-Check database to ensure it exists Working Phone Number V Actual Amounts—(i.e.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? �Inone,note that. Disposal Information—where and who? If none,note that. pplicant Signature—understand what is listed and noted. taff Initial—any questions,know who to ask. T_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.