HomeMy WebLinkAbout0138 LINCOLN ROAD - Health 138 Lincoln Road
Hyannis P
A = 270 055 `
I�
lip
0
I TOWN OF BARNSTABLE
"LOCATION`` �.��8 lJ tvts�� Lf`� SEWAGE #
VILLAGE i- AftOWI C ASSESSOR'S MAP&LOTh-
�T�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1 bC)n gtar
LEACHING FACIL=: (type) 4 �— (size) '
NO.OF BEDROOMS
BLUDER OR OWNER P l DATE: 1\2 A�b COMPLIANCE DATE:
Separation Distance Between the: .
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility iao 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 leachin facility) lV Feet
Furnished by
cGs CS
Q D
E
'} TOWT7, F B STABLE
~LOCATION SEWAGE # 922VILLAGE ASSESS S MAP & LOT 2-10 -D5S
INSTALLER'S NAME&PHONE NO.
'i SEPTIC TANK CAPACITY i 5 a �2_
BEACHING FACILITY: (type) s i �A/CO-(size) $eCC� � /
N0.OF BEDROOMS
k (
`BUILDER OR OWNER r9✓I lO 4e 4�
PERMIT DATE: 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
VV �
No �0 ff FEE
Board of Health, !-1r�s= lg�-Si��P MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade Abandon( p`- O Complete System,Individual Components
Location ,, g Owner's Name A-4%6-
Map/Parcel# Q 5 Address 1] �.
Lot# It: Telephone#
Installer's Name -� Designer's Name
Address S �1 ��� q Address LS340
Telephone# y _ 0 Telephone# 9
Type of Building 2Q n 3 Lot Size Q�sq.ft.
Dwelling-No.of Bedrooms �<<� q-41 6_ `�'1 (l.2SlC!►11 Garbage grinder (/1�IA
Other-Type of Building �[X'1� �� No.of persons 16C Showers (Vf,Cafeteria (Vj
Other Fixtures
Design Flow (min.required) 33o gpd Calculated design flow �� esign flow provided 3 L gpd
Plan: Date g\'XiON Number of sheets ' Revision Date
1�
Title �C��pSQ&
Description of Soil(s) AD t7 cx, //11 cc
Soil Evaluator Form No. Name of Soil Evaluator0 Q 61jAR! ate of Evaluation d
�+ Sys Er
DESCRIPTION OF REPAIRS OR ALTERATIONS
The un ersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furtherr ees tot not to pla a temA*n operation until a Certificate of om lipnce has been issued by the Board of Health.
Signed Date V
A
y�ep�tivrf =,gu
v'v�.•-'i.s.l:a -ky r
No � a FEE
COMMONWEALTH OtMASSACHUSETTS,
Board'of Health, MA. i
APPLICATION VO DISP®SA SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade><Abandon( - ❑Complete System )Vndividual Components
Location , —65 L .l Owner's Name \J A' \J
Map/Parcel# Address
Lot# jTelephone#
Installer's Name Designer's Name
Address S -- S� C� Address OX Ga 4 10-) 'VV, 0 7-S310
7 Telephone# coL-\8_ 5 S\o Telephone#
4 8 -O 9 to
Type of Building S\clip Lot Size a 4(Da sq.ft.
Dwelling-No.of Bedrooms �)o s-16gr, �i 6 e 51Q11 Garbage grinder (AN
Other-Type of Building N nn e_ No.of persons Showers' p _� (K�,'Cafeteria (y�
Other Fixtures L P,,a
s��c
Design Flow (min.required) �,�i' gpd Calculated design flow �!)C UDesigi flow provided 3 Q gpd
Plan: Date C1,'7,)O\ Number of sheets ' Revision Date
t -
Title-
Description of Soil(s) k�Q —�L� '7\CA`, '
Soil Evaluator Form No. "Name of Soil Evaluator(/1 A. �* A? Date of Evaluation q I as!03
DESCRIPTION OF REPAIRS OR ALTERATIONS
The unrersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further _ ees tol not to pIaqe)t1r.e1systemjn operation until a Certificate of ompplipnncehas been issued by the Board of Health.
Signed Date 161031L6
v
7 � T FEE
COMMONWEALTH ®F MASSAC14 lJ SETT S
Board of Health, hn�b)e, MA.
�ndividual
CERTIFICATE ®f COMPLIANCE
Description of Work: Component(s) 0 Complete System
The u esigne here y certify that the Sewage Disposal Syst Lm; Constructed ( ),Repaired ( ),Upgraded (Lj/,Abandoned ( )
by: b 2C� 5
at J9 Ljna) n t ariann 1,5
has been installed in accordance with the provisio of 310 CMR 15.00 (Title 5) and'the approved design plans/as-built plans relating to
application o.2' 3—'441 dated 13 03 . Approved esi n Flow (gpd)
Installer !I U_
Designer: Inspector: _ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. !
FEE,
6�2
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ,rl 17 itl./✓�� MA.
�. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construlctt(( ') Repair( ) Upgrade d Abandon( ) an individual sewage disposal system
at 138 i.���r�l (� c��;� , ►T U a n s / as described in the application for
l
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health
TO�BST;,"-
SEWAGE #
LOCATION 2-10 C55
VILLAGE
ASSESS 'S MAP & LOT -
INSTALLER'S NAME&PHONE -
SEPTIC TANK CAPACITY
ize)
LEACHING FACILITY: (type) — y
NO.OF BEDROOMS
BUILDER OR OWNS
03
PERMITDATE: to 3,03 COMPLIANCE DATE: f�
Separation Distance Between the: Feet
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
exist
Edge of Wetland and Leaching Facility(If any Feet
within 300 feet of leaching facility)
y
Furnished b
i
I
5eN - 20- 01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304
A
srz3;oi
NC)TICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
PERCOLATIO-N TEST AND SOIL EVALUATION EXEMPTION'
FORM
ceovv Er4 hereby certify that the engineered pian signet by 1re
.
clatec 1 O 03, concerning the property located at
� __�I�iC�lrl �• . t"\�.tstQn\S meets all of the
fctlo,v,n; �:nteha: V
• This failed system is connected to a residential dwelling only. There are no
.ommer:ia! or business uses associated with the dwelling,
• The soil is ciasst;:ed as CLASS l and the percolation rave is less than or equal to
m:nutes per inch. The applicant may use hismncal data to conclude this f3c: or rna;y
:onduct pre!imwary tests 3t the site without a health agent present.
I
• T her= :s no increase in flow and/or change in use proposed
• here are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than fourteen
l feet aogve the maximum adjusted groundwater table elevation, fAdiust the
nun(Iwater table using the FHmptor method when applicable)
Please complete the following:
�. I np D! Ground Surface: Elevation (using GIS information)
6; G.Vy' E!evacor, I- adjustment for inigh G.W. _'0C.•. _ __-ae.a
,) FTT..RFHNCF.. EETWEEt\1 r\ and B CAI a
G.'11TD __ DATE:
3asec j-oR trio atove ir.formacion, a reoair perrrut wil! be issued for aedroom..s
`,;a ,ddiw)na[ bedrooms are authorized to future without engineer ec ,
el rt'.. s_r tom plans
1,7:1in:q'Aci Puccxm;
Permit Number: Date
Completed by:
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: LINC17\Z ,ntewp; ttt/�Q[�(1�S 1 � Lot No.
Owner: Address: 2Z nc.eftc,n
Contractor: '3'A%Z Q r%,1 IMEVrVC&A Address: !Z= �ca�. G-�0.�f1r�c�1�1n bN f`lr Oo)s at"
Notes: IJ
STEP 1 Measure depth to water table
tonearest 1/10 ft. .............................................................................. .Date CI �S
mon /day/year
I
• I
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well.................................................... M�9
OBWater-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to Q'h
water level for index well ........................... • ,
month7year
l
STEP 4 Using Table of Water level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water level zone (STEP 28)
determine water-level adjustment .
.........................................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) .................................................. .....................................
a
Figure 13.--Reproducible computation form,
15
CARMEN E. SHAY (508)-548-0796
ENVIRONMENTAL SERVICES,INC. P.O.Box 627,East Falmouth,MA 02536
October 15, 2003
RE: Certification of Title V Septic System Installation:
Residential Property 138 Lincoln Road,Hyannis,MA
Dear Sir or Madam:
On October 10, 2003, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at 138
Lincoln Road, Hyannis, MA, based on a design drawn by Shay Environmental Services on October 8,
2003.
C��
Certify That The Septic System Referenced Was Installed Substantially According to the Plan
I Certify That the Referenced Above Septic System Was Installed With Changes but in
Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow.
I
The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is
Required.
If you have any questions, please do not hesitate to call the undersigned at(508)-548-0796.
Sincerely,
CARMEN E. SHAY
ENVIRONMENTAL SERVICES,INC.
�ZH OF&I
CARMEN
E.
SHAY
. 1181
Carmen E. Shay, R.S., C.S.
President G's T E'
SANITAR�Pa
f
COMMONWEALTH OF MASSACHUSETTS t/
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONNE\TAL PROTECTION
ONE WINTER STREET. BOSTON. MA O'_IOS 61?-:9.•S:CG �q`�#t �
TRLMY CO)Z-
�7LLIA%'F.��LD •;.:. Fr rp e7 Q Secre r
Governc y�p��9q ..1�1 D.4\D B 51RL'1-_
ARCED PALL CELLUCCl _ yoFysf `99 Coma issior_.
SEWAGE DISPOSAL SYSTEM INSPECTION
Lt.G vi:rnoi SUBSURFACE � 4c
PART A G'
oil CERTIFICATION
� I ass :. . . . • . :._. _L_: ..-.-
(r�►.�coltv�.. `°�t''�"� Address of Owner:__!DWk_Z` ktoV7
Property Address; t i 1-czA ;aS1 �sTr�.
Date of Inspection:
"qf different) c o
Name of Inspector: .i .*•o - �« ��ut�+. 02e3I
1 am a DEP ap roved system inspector pursuant to Section 15.330 of Title S (310 CMR 15.000)
Company Name: s_- 7. ar�i'
Mailing Address: 2 O l;o,c e-73�41 H Ke EesL H r7-0 Cl
Telephone Number. ,f So
CERTIFICATION STATEMENT
I cern� that 1 have pe•sonalh ir.spec-ed the sewage d!s*osal systern at this address and tha: the information reported be!o% is true. accurate
and comolete as of the time of inspectoo-.. The inspect:on %as pe-:ormed based on my training and experience in the proper iur:eicn and
maintenance o;on-site sewage disposa; systems. The n•stem:
Passes -
_ Concioonaii% Passes
_ ♦eecs Furthe• Eva!uaro^ E�. the Local Approving Autnont%
Fa.!s
Inspector's Signature:
Date: ` �\
T;,e Svse^ Insre_o• sha'' submu a copy of this inspec,on repo- to the Aporoving Authority within them (301 days of completing this
inspection. It the s\stern is a shared cvsiem o- has a des-gn flow of 10,000 gx or:greater, the inspe,or and the syste-r owner sl•,all submit
the redo^ tc the a;oropnate reg oral o^ice of the De;a-ment of Envtrcnmenta* Frotecicr.. The crigma! should be se�e to the s�ste^, ov.ne
and copes .-n:to the buyer, ii applicable.and the aprroving authority
INSPECTION SUMMARY: Check A, 'E, C, or D
AI SYSTEM PASSES:
I Have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 13.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BJ SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass- section need to be replaced or repaired. The system, upoI
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no. or not determined (Y, N. or NDi. Describe basis of determination in all instances. If 'not determined', explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (anachedi )indicating that the tank was installed within twenty (20) years prior to the date of the inspection; o
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tanl
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
lr•,•-z.d Ps go 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f �
PART A
CERTIFICATION (continued)
Property Addrass:
Owner:
Date of Inspection:
BJ SYSTEM CONDITIONALLY PASSES tcontinr,!-d
Sewage backup or'breakout or high static water level observed in the distributio box is due to broken or obstructed
pipets) or due to a broken, sealed or uneven distribution box. The system wil pass inspection if(with approval of the
Board of Healthi. Describe observations:
broken pipefs) are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to br en or obstructed pipe(sl.,The system will pass
inspection if tw•ith approval of the Board of Health):
broken pipets; are replace. .. ..
obstruction is removed
C] FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require furthe•.evaluation by the Board of Health in order to determine if the system is failing to protec the
public health. saiery and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE INE5 THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
�
_ Cesspool or priv is within 50 feet of a surf Ee water
Cesspoo! or pri%%- is within 50 feet of a bo 'eying vegetated wetland or a salt marsh.
2. SYSTEM WILL FALL l INLE55 THE BOARD OF HE�ILTH UtiD PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINE5 THAT
THE SYSTEM 15 FUNCTIOti1tiG N A MANN THAT PROTECTS THE PUBLIC HEALTH AND SAFFE Y AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supC y.
_ The system has a septic tank /d soil absorption system and the SAS is within a Zone I of a public water supoiy we!l.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank!and soil absorption system and the SAS is less thar. 100 feet but 50 feet or more from a
private water supply well/uniess a we!I water analysis for coliform bacteria and volatile organic compounds indicates that
the we!I is free from polpion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
.less than 5 ppm. Meth used to determine distance (approximation not valid).
3) _ OTHER
J.
Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate either "Yes" or "No' as to each of the following:
1 have determined that the system violates one or more of the following failure criteria 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 necessan• to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overload or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surf a waters due to an overloaded or clogged SAS or
cesspool.
Stark !squid level in the distribution boa above outlet invert due o an overloaded or clogged SA5 or cesspool.
Liquid depth in cesspool is less than 6" below invert or availa a volume is less than 1/2 day floe.
Required pumping more than 4 times in the last year NOT ue to clogged or obstructeo pipes .
Number of times pumped _.
Any portion of the Soil Aosorption Svstem, cesspool or riv)• is below the high groundwater eievatior.
Ar. por:on of a cesspool or privy is within, 100 feet f a surface water suppiv or tributary to a surface water supply.
Any portion of a cesspoo' or prwy is within a Zon I of a public well.
Am portion cf a cesspool or prig\ is within 50 f t of a private water supply well
_ Anv por,.or. of a cesspool or pri%-• is less tha 100 feet but greater than 50 fee: from a private water suppiv well with no
acceptable Nate, qualm analysis. If the wel has been analyzed to be acceptable. attach cop% of well water analysts for
coliform bacteria volatile organic e;ompou ds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
hou must indicate ei:he, "Yes' or "No-,as to each of the following,
The folio";ng criteria aop'% to large systems r addition to the criteria above:
The system serves a facilir\ with a design fjow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and safety and the envrron dent because one or more of the following conditions exist:
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 suppl}
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.
I
(reviled 04/35/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propert% Address: ks� �tiCA�N
Owner: HaT,
'Date of Inspection: I iz(Ah,&
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least 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 recenti\ or
as pan of this inspection.
As built plans have been obtained and examined. Note if they are not available with MA.
The fac:lr. or d\%elltng %%as inspected for signs o-sewage back-up.
_ The systern does not receive non-sanitary or industrial waste flow.
The site ..as inspected for atgns of breakout.
All system components. excluding the So![ Aosorptton System, have been located on the site.
The septic tans: rnanhoies Nere uncovered. opened. and the interior of the septic tank was inspected for condition of
baffies or tees. materia' o• construction. dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on
The iacdw, o\%ne, ,anc occupants. if drherent rrom owners were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex Plan at B.O.H.
Determined to the field of an. of the failure criteria related to Part C is at issue, approximation of distance is
"T unacceptabie (13.302:3);bIl
I�
(revised 04/25/57) Page 4 of 10
f
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Propert% Address: N3�b L"r-CGAI^j jP 4 1
Owner:`�61T-
Date of Ihspection:
FLOW CONDITION'S
RESIDENTIAL:
Design floes :;0t) e.p.d./bedroom for S.A.'S
Number of bedrooms�2
Number o'current residents CD
Garbage g•: der (yes or no:-: 10
Laundry con-ected to system (yes or no!
Seasonal use Ives or no,: .3
Water meter readings, if available (last two i2: year usage (gpd): U — ow
Sump Pump Ives or norms
Lai: date o'occupancy
COMMERC i AUINDUSTRIAL:
Type of establishment
Design fio%% _gahonsida\
Grease trap present rues or no
Industrial 1laste Holding Tani; present. lees or no_
':on-sanrtan waste discnargec to the T,t,e 5 system- Ives or no
\later meter readings. if a\,ailabie
Las:gate o: o c"pane.
OTHER: .De:cnbe
Last sate of occuoanc,
GENERAL INFORMATION
PUMPING RECORDS and source of tniormation
N�{4
System pumped as par, of inspection: tees or no._
If yes, volume pumped ¢allons•
Reason for pumping
TYP OF SYSTEM
Septic tank/distribution box/sod absorption system
Single cesspool
Overflow cesspool
Prt\,).
Shared system (yes or no) (if yes, attach previous inspection records, if any)
1/A Technologv etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site. (yes or no)
(revised 04/25/9*7) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Gi&co IN
Owner: (� .
(Date of Inspection: I CZ(�IG p
BUILDING SEWER: ` lU
(Locate on site plan) N0
Depth below grade.
Material of construction: _cast iron _40 PVC _other (explain`
Distance from private water supply well or suction Ii
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: WS
(locate on site pl
Depth below grade ILLJ
:katerial of construction: concrete _meta _Fioergiass _Polyethvlene _othenexplain'
If tank is metal. Iis: age _ Is age cor.f,rmec o\ Ce^:f,ca:e o: Compiiance
Dimensions J(1 0
Sludge depth Q z�i(
.Disiance from top o: sludge to bororn of ou!ie: tee o• ba�';e
Scum thickness 141 �J
Distance from top o: scum to top of outlet tee or bade 0
Distance from bottorn of scum to bo:r �e, tee c bar-e
How, dimensions were determmec �
Comments.
(recommendation for pumping. condition of inlet an outle! tees or baffles, dipth of liquid level in relat�o to outlet invert, stru ral
integrity, evidence of leakage, e:c.i �' -Fe
U(
GREASE TRAP:
(locate on site plan.:
Depth below grade:
Material of construction: _concrete _metal Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum.thickness:
Distance from top of scum to top of outlet tee or baffle.
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of islet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.;
(rep•:i.d 04/25.'97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.tit
PART C
SYSTEM INFORMATION (continued)
Property Address:
Date of nspection:1
TIGHT OR HOLDING TANK: W� 7ank must be pumped prior to, or at time, of inspection)
(locate on site plan,
Depth below grade:
Material of construction. _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capac;h•: gallons
Design floe` galions-da,
Alarm level Alarm ;n „orking order _ Yes; _ No
Date of previous pumping
Comments
(condition of inlet tee. conditior o- a!arm and float switches. etc.)
DISTRIBUTIO's BOX:IS
(locate on site pan
Deah of liquid le e' aoove out e: irne l%y OU�
Comments 6
tnote ;f leve! and distribu•1 n 2 eau-' vidence of olids rryov r• evidence of I ka a into or out of box, etc.)
17-i�ox L5 o i , s ��fl��ry u Ikip- f�c�Ca
PUMP CHAMBER:
(locate on site plan.
Pumps in working order: (Yes or No'
Alarms in working order (Yes or No
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
G.
N
(revised 04/25/9') Pago 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Prope drllrssl, o Gwclo IN
Owner: �
Date of Inspection:,
SOIL ABSORPTION SYSTEM] (SAS):_rj/AC
(locate on site_plan, if possible, excaWo'n not required, but may be approximated by non-intrusive methodsi
If not determined to be present, explain:
Type:.
leaching pits. number. (/
leaching chambers, num r:_
leaching galleries, number.
leaching trenches, number,length:
leaching fields, number, ci,mension.s
overflow cesspool, number
Alternative system
Name of Tecrmoiog,.
Comments
mote c ndrtion of$ it. signs of hydraulic failure, lever of pondm t g• c nd� of veget on c.1 `
i C 1 tf
Lc
.CESSPOOLS.
(locate on site plar.
Number and coniigura:�on.
Depth-top of liquid to inlet Inver,
Depth of solids laver
Depth of scum layer.
Dimensions of cesspoo:
Materials of construction
Indication of groundwate-
inflow (cesspool must oe pumpeC as par, of inspection:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:—QV
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page a of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propert} Add s:
Owner: it"fi,
Date of Impection:1 17 '��9�
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
L
36'
i
(revised 04135/57) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propertv Address-
Owner: �Q`
Date of Inspeciion:
1rib
Depth to Groundwater 2�Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Desigi, Plans on record
+_ Observation o'Site (Abuning properry. observation hole, basement sump etc.)
Determine it from local conditions
Crnec� with loca! Board o• neaar
Chec'K FEMA Maps
Check purnping records
Check local eaca\arors. installers
Lse LcCc Da:a
r•
Describe in vour o� %•.oros no••+ \o:: estabh5hed the High Groundwater Elevation. (Must be completed!
Qo( C'S kv I, oyC- :F/VIZ?-S�tt � O''vSr ffj
lzav:aad 0�;25'9'. Page 10 of 10
o�trcro` The Town of Barnstable
Health Department
""tea"
rua 367 Main Street, Hyannis, MA 02601
,b,9. `F
Office 508-790-6265 Thomas A. McKean
FAX 508-775-3344 Director of Public Health
June 26, 1992
Mr. and Mrs. Richard O'Brien
77 Beal Street
Hingham, MA 02043
Dear Mr. and Mrs. O'Brien,
A lead paint determination was made of the property owned by
you at 138 Lincoln Road, Hyannis by Donna Miorandi of the
Barnstable Health Department on June 24, 1992. This
determination revealed the presence of lead paint in
violation of Massachusetts General Laws, Chapter 111,
section 197 .
Please contact Donna Miorandi at 790-6265 as soon as
possible to discuss your responsibilities in this case, and
the material enclosed.
Massachusetts Lead Poisoning Prevention Regulations require
that you provide to this office, within 60 (sixtyL days of
your receipt of this letter, a written contract with a
licensed deleader to abate all lead violations existing in
the dwelling unit, including interior and exterior common
areas. You must provide the deleading contractor with a
complete inspection report from a licensed lead paint
inspector.
The deleading contract must be signed by the contractor and
by you; it must specify that all violations on the interior
of the unit and the interior common areas will be deleaded
within 90 (ninety) days of your receipt of this letter, and
that all exterior violations and/or window replacement will
be complete within 120 (one hundred and twenty) days.
This Department is required by law to file a case against
you in court if it has not received a copy of the deleading
contract by the sixty-first day, or if the above timelines
for interior and exterior deleading compliance are not
adhered to as documented by a private lead paint inspector.
f In a criminal case, you may be fined by the court up to $500
for each day of non-compliance.
Only contractors licensed by the Department of Labor and
Industries as deleading contractors may engage in the
removal, covering, or replacement of lead hazards. Neither
you nor anyone in your employ nor the occupants of this unit
may remove or cover any lead paint unless that person is a
licensed deleading contractor.
The contractor must provide written notification to the
Department of Labor and Industries, all residential
occupants, the Board of Health, and the state Childhood Lead
Poisoning Prevention Program (CLPPP) at least five days
before any deleading work begins. It is your
responsibility, as the owner of the premises, to make sure
that the contractor sends the completed forms to all
'E parties.
All occupants and pets must be out of the dwelling unit for
the entire time that interior deleading work is in progress.
They may . not return until a licensed private inspector
approves reoccupancy by conducting an on-site reinspection
of the unit; this will be done after the final deleading
clean-up. Deleaded windows and doors must have all panes of
glass intact and must be weathertight.
i
You are required to provide written notice of the presence
of lead paint to all other occupants of the building.
Notice to Tenants of Lead Paint Hazards is enclosed for
that purpose.
You are required to send a copy of the inspection report and
the closed order to all mortgagees and lienholders of
record.
Questions regarding Department of Labor and Industries
regulations should be addressed to the DLI office (617-727-
1932) . Questions regarding the Department of Public Health
regulations should be addressed to the CLPPP central office
(800-532-9571) or this Department (508-790-6265) .
k0 0
o v.
Health Insp or- Director o Public Health
cc: Susan Rask,
Barnstable County Health Dept.
0[INC r�r
The Town of Barnstable
Health Department
ram& 367 Main Street, Hyannis, MA 02601
Office 508-790-6265 Thomas A. McKean
FAX 508-775-3344 Director of Public Health
June 26, 1992
ORDER TO CORRECT VIOLATION
Mr. and Mrs. Richard O'Brien
77 Beal Street
Hingham, MA 02043
The property owned by you located at 138 Lincoln Road,
Hyannis was inspected on June 24, 1992 by Donna Miorandi
Health Inspector for the Town of Barnstable who has
determined certain portions of the aforementioned
residential property to be in violation of the State
Sanitary Code Chapter II, "Minimum Standards of Fitness for
Human Habitation, " 105 CMR 410.750 (J) . This violation also
constitutes a violation of the Regulations for Lead
Poisoning Prevention and Control, 105 CMR 460.000, and
Massachusetts General Laws, Chapter 111, section 197.
Conditions exist in this residence which may endanger and/or
materially impair the health of the occupants of these
premises.
DECLARATION OF EMERGENCY
The Director of the Childhood Lead Poisoning Prevention
Program and the Board of Health declare that the presence of
the aforementioned violation presents an immediate danger of
lead poisoning to one or more occupants of the premises and
that this constitutes an emergency pursuant to Massachusetts
General Laws (MGL) , Chapter 1, Section 400.200 (B) .
ABATEMENT OF LEAD VIOLATIONS
M.G.L. Chapter 111, Sections 190-199A and the Department of
Labor and Industries Deleading Regulations, 454 CMR 22.00,
as well as the Regulations for Lead Poisoning Prevention and
Control require that only licensed deleading contractors
conduct residential lead abatement. This means that you
cannot conduct lead abatement yourself or hire anyone other
than a licensed deleading contractor. Violations of this
requirement shall be punished by a fine of not less than
five hundred nor more than 1500 dollars for each offense.
ORDER
You are hereby ordered to remedy all violations of M.G.L.
Chapter 111, Section 197 and 105 CMR 460.000 as identified
by a licensed private lead inspector. You must contract in
writing with a licensed deleader and a signed and dated copy
of the contract must be received by this agency within 60
(sixty) days of your receipt of this Order. Said contract,
must specify that all violations on the interior of the
residential premises or dwelling unit and interior common
areas will be abated within 90 (ninety) days of receipt of
this Order. In addition, the contract must specify that all
violations on the exterior of the residential premises and
exterior common areas will be abated within 120 (one hundred
and twenty) days of receipt of this Order. If windows are
to be replaced and you can demonstrate that an order had
been placed for the windows within 60 (sixty) days of
receipt of this Order, you will have 120 (one hundred and
twenty) days from receipt of this Order to install the new
windows.
You must comply with all applicable sections of 105 CMR
460.000. Compliance will be determined by this agency's
receipt of the appropriate documentation within the
specified deadline, including: a copy of a signed and dated
deleading contract within 60 days of receipt of this Order;
a Letter of Lead Paint Reoccupancy Reinspection
Certification issued by a licensed private lead inspector
within 90 days of receipt of this Order; and a Letter of
Lead Abatement Compliance issued by a licensed private lead
inspector within 120 days of receipt of this Order. In
addition, a copy of the deleading notification must be
received by this agency at least five days prior to any
commencement of deleading.
PENALTIES
Failure to comply with this order will result in ' criminal
prosecution. The law provides penalties of up to $500 for
each day of non-compliance. In addition, you may become
liable for civil punitive damages equal to three times any
actual damages for failure to comply with this order of a
child becomes poisoned.
CORRECTION OF VIOLATION BY CODE ENFORCEMENT AGENCY
If the dangerous levels of lead are not abated within the
time periods stipulated above, this agency may contract with
a licensed deleader to correct the violation and bill the
owner, or initiate court action to reimburse itself.
Thomas A. McKean,
Director of Public Health
I —
jf
971451
�� I Vcrn�'.��c�m��lr�,vrc�
Witllllrm F.Weld S��
ChUdhood Load
Govemor Polsonlno
.vtd P. r ,// �+ !!!!// Prevsntlon Progmm
terry ,rp JCK Vo&&D L /ee4 Ooatonf ffW 02,00-s 7 800-532•9571
)"W K Mualp.n 617-1fl22-s7oo, 9Gw 617-su-87ss
Commb.l0(W
LEAD DETERMINATIONS REPORT FORM
Date of Determin 'on:
Inspector:
License #:
Method Used: Sodium Sulfide Expiration date:
X-Ray Fluorescence Model:
Q Serial :
U al
Property Address: udCO Apt: fi
Description of Proper y:
ti Single family
Multi-family # units
Garage .
Fence
Other structures
Age of Property: ---�P-- Pre-1978
Post-1978
S 4ge / ^LA
Occupant: /}� t-
Occupants der s 'x years of age: Q
TA n/ DOB:
DOB:
DOB:
DOB:
Occupant' s Telephone: —
0
Property Owner's) :
Owner's Address:
Owner' s Telephone:
An X-ray fluorescence reading greater than 1. 1 mg/cm2 or a gray or
. ' black reaction to sodium sulfide indicates an illegal level of lead
and constitutes a positive determination.
Any removal, replacement, or covering of lead paint as a result of
'this report or subsequent inspection must be performed only by a
de leading contractor licensed by the Department of Labor and
;tlndustries.
ff � 175
Pb .
SOURCE
LOCATION
Window parting .
1, Child' s bedroom bead/exterior sill area
bedroom Window sill
2, Child' s 3, Living room Window parting
bead/exterior sill area
Window parting
q , Kitchen bead/exterior sill area
Flaking paint
5. Interior. . ...
I
Flaking paint
6. Exterior I
Cellar window units
7 . Exterior
Window sills below 5 '
g, Exterior Main entry door or door
9, Exterior casing
outside corner of baseboar
� 10. Interior
Kitchen or Bathroom Chair rail
11. Window sill
12 . Bathroom
Threshhold
13 . Exterior Stair tread or stringer
14 . Interior hallway
(common area) I
Balusters
15. IInterior hallway
(common area) I
� Door casing
16. Interior hallway I
(common area) or riser
Stair read I
117 . I Porch I Railing cap I
18. Porch
Balusters
19 . Porch I
Support columns
20. Porch (<6" diameter or square)
Staircase stringer I
21. porch I
Bulkhead I
22. I Exterior casing or jamb
i outbuilding Door
23 . GaY..aae/
176
24 . Interior Closet door or baseboard
(uncapped)
25. Interior Cabinet door, shelf, or
wall
26.
27.
28.
29:•
30.
Y;
Ali.'•
rig:'"•
f7i'
yt:6:
y:•
177
d'
I
1
09/10/92 16:48 $617 380 5879 STOP&SHOP la 001.
Post-V brand fax transmittal memo 7671 #of pages ►
70 From
Co. Co. . .
Dept. Phone#
7—
Fax# Fax#
S�fr " 4 3 ly
S�fcar rs 77 Beal Street
Hingham, MA 02043
September 10, 1992
Ms. Donna Miorandi
Health Inspector
Town of Barnstable
367 Main Street
Hyannis, MA 02601
Dear Ms. Miorandi:
I called your office today at 9:00 a.m. and. spoke to Mr. Gerry Dunning in your
absence. I wanted to drop you this letter to confirm our telephone conver-
sation of 8/7/92 at 9:20 a.m. regarding your Lead Determination Report on our
house at 138 Lincoln Road in Hyannis. Since the house is all knotty pine
panelling - we never even thought the house would have any lead paint. I am
attaching a copy of the report which lists the window parting bead/exterior
sill area where the lead paint showed up.
Our tenants, Timothy B. Furlan and Pam Lowing, gave their notice to us at that
time, and told us they would be vacating our house no later than 9/l/92. We
also received a call from a real estate agent requesting a recommendation for
them at that time. In order to protect ourselves, I called to ask if there
was anything else my husband or myself needed to do regarding this .report..
You advised me that there was nothing more we needed to do since the tenants
had given their notice. Your office does not proceed on anything further.
The reason I am sending this letter is that the tenants are still looking and
haven't moved as yet, and I wanted to make sure my letter was a matter of
record. .
Thank you .for your help in this matter.
Sincerely,
.Dorothy O'Brien .
Enclosure
L
WIU1tm F.Weld �� Ctwdhood Lead
C3overr�or �tli�fi /� 1�G Poisoning
&vW P.Forabenp Prevention Program
secretary cl04e't1PJ&e"4 00&40YIr4If Q2 30-&V7 e00-532•9571
r. Dam K MU11100 617-tw-3700, 9=617-S22-87SS
Commissioner
2.u fl �
LEAD DETERMINATIONS REPORT FORM `� '"`�`
Date of Determin ' on:
Inspector: CL O
License #:
Method Used: Sodium Sulfide Expiration date:
}{-Ray Fluorescence-" Model:
Serials :
,3 �li� D u
Property Address: Apt.
Description of Proper y:
Single family
Multi-family units
Garage
Fence
Other structures
Age of Property: Pre-1978
Post-1978
occupant: ( �a IP
IL
Occupants u der s 'x yeas of age:
o
D DOB: t� o
DOB:
DOB:
DOB:
Occupant' s Telephone:
0
Property owner(s) :
` - owner's Address..
Owner' s Telephone; ..
An X-ray fluorescence reading greater than 1.1 mg/cm2 or a gray o;
black reaction to, sodium sulfide indicates an illegal level of lead
and constitutes a positive determination.
7 Any removal, replacement, or covering of lead paint as . a result of
this report or subsequent inspection must be performed only by a
µ de leading contractor licensed by the Department of Labor and
r ,�x, Industries.
y*'r 175
iJ v •
Pb
SOURCE
LOCATION .
Window parting
1, Child's bedroom bead/exterior sill area
Window sill
Window ng
-
2. Child' s bedroom � arti. ` ►
3 . Living room _ bead/exterior sill area
Window parting _
4 , Kitchen bead/exterior sill area
Flaking paint
Interior. . ... _
Flaking paint
6, Exterior
Cellar window units
7 , Exterior
Window sills below 5 '
8 , Exterior Main entry door or door
9 , Exterior casing
outside corner of baseboard
10. Interior
11
Kitchen or Bathroom Chair rail
Window sill
12 , Bathroom .,
Threshhold
13 , Exterior stringer
Inter
Yior hallway Stair tread or
14 . ..
(common area) I
t III Balusters
15, l Interior hallway
` (common area) `
allway Door casing y
inte,._ior h
(Common areaj
i treaa Or riser
Stair
` 17 . Porch
? Railing cap
18 . 1 porch
Balusters
i 19 . porch "
Suppo-t columns
20. porch (<61, diameter or square)
stringer
Staircase `
21. POrch i
l Bulkhead
Exterior
22 , Y arub
Garaae/outbuilding Door casing 7 o-
23 -
176
50
: 380 5879 STOMSHOP -- 19004
.-
24 . Interior Closet door or baseboard
(uncapped)
25. Interior Cabinet door, shelf, or
wall
26.
27. --
28.
2 9:"
30.
IL
177
yp�THE>O`4 The Town of Barnstable
•J Health Department
{ """"j 367 Main Street, Hyannis, MA 02601
rm
�0■RR M.
Office 508-790-6265 Thomas A. McKean
FAX 508-775-3344 Director of Public Health
September 8, 1992
Mr. Dennis Hackett
c/o Fairmark Company
715 Boylston Street
Boston, MA 02116
Dear Mr. Hackett:
This letter is being written as a result of our phone conversation
today regarding the property located at 1167 Phinney's Lane, Centerville.
The Health department received a complaint last week regarding the
condition of the hallways and apartments of this building. The hallways
have many dead and living bugs. Exterior doors appear to be open most of
the time and some are not self-closing. The hallway carpeting is quite
dirty as well as the walls. They exhibit signs of age and deterioration.
The laundry room is very unsanitary and appears to be inoperable.
As we discussed on the phone it is acceptable to this department for
you to have the building fully exterminated on September 16, 1992.
Thank you for your quick response and cooperation in this matter.
Sincerely,
o �
PP
Donna Z. Miora d
Health Inspector
t} TOWN OF BARNSTABLE
LOCATION SEWAGE��g J„I �y � SEWAGE # �� I
VILLAGE ASSESSOR'S MAP & LOT 9-70- 06'S"
INSTALLER'S NAME PHONE NO.
` I
SEPTIC TANK CAPACITY 10cru .
LEACHING FACILITY:(type) (size) [Oec,
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER PUMLm.-
BUILDER OR�OWNER ��, �-ZJ Q(Z,l
DATE PERMIT ISSUED: In -
DATE COMPLIANCE ISSUED: /CG
VARIANCE GRANTED: Yes No
_-
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Fim............. ....��
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH pVM
TOWN OF BARNSTABLE
Application for Disposal Work, C�oustr
V
Application is hereby made for a Permit to Construct ( ) or Repair ((/�an Individual Sewage Disposal
System at:
. y......� .................... ...... . .. : -=--- .. .........................-----
L cat'on- ddress r Igo.
.� : .. .............................. ..........: .... ��.. ........g, I 4� .� . .
r Own _ ddress
Installer ' Address
Type of Building Size Lot................... .......Sq. fee
Dwelling—No. of Bedrooms......... :..__....Expansion Attic ( ) Garbage Grinder ( )
per,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q, - Other fixtures -----------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons ' Length................ Width................ Diameter................ Depth.................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_...................sq. ft.
x
Seepage Pit No--------------------- Diameter.................... Depth below inlet.........._._...._.. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.............................................------------------•--------- Date--------------.............------.......
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
LL, Test Pit No. 2-----------.....minutes per inch Depth of Test Pit.................... Depth to ground water.........................
a ----------------------------------------------------------------------------------------------------.........................................................
0 Description of Soil-------------------------------------------------------------------------------------------------------------------------------------------------------------------•---
-------------------
W ---------------------------------------------------------------------------------------------------------------------------------------------- ------- - ----------
U Naty�re of Repairs or Alterations— nswer wheq,�p licable_._ � ��� _._:
..... .: :::::::::::..:.::.:::: ..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with.
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance been issued by the board of health.
Signed----- ...C� % es�. . ----------------------
Date
Application Approved By ------------- ". 1.f2...^�. ..�.�`.
-.....------------------------------------------------------------------------ Dare
Application Disapproved for the following reasons• ----------- .............-------------------------------------- ---------------------------------..................................
---------------------------------------- ---------c.......-----------------...----- --- ...------------ . ------. ------------------............................................................ ..........
Permit No. 1....a SO..�----------- ------------ Issued --------------------...----------------------------- Date----..
Date
No._ a= d I f FiE$....Z�.... �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. TOWN OF BARNSTABLE
Applirattun for Uippv'm Works Tvnstrur#tun
Application is hereby made for a Permit to Construct ( ) or Repair ((�an Individual Sewage Disposal
System at: /_
L icat on-Address
..,.. - ____......... .. ..... .. . ......_. -- asaa --------
_„------> ..
ddres� �
Installer r Address +
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.......... S----------------------------Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type of Building No. of persons............................ Showers — Cafeteria
04 Other fixtures ...---------•-------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................. Depth................
x Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--_--------------_ Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
GL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ----------------------------•--•-••---------------------...-•-•-••----•---------------------.--------------------•-...-----.._........-------------------_..
0 Description of Soil------------------------------------------------------•-•----------•--------------------------------•--•-----------�:--•--------:-----------------------...........---
x ).
V .-------------------•---•••----......--••-•--••----•------•••---........---.........----------------......•-•••-••••-------•...-•-----•-•----------------f.............................................
t
_., - •••------- -•----------•---------------
V Nat re of Repairs or Alterations—Answer when applicable.-. �?-. .....97.4�._.. --_ __.� --
..---•--..tea ='---. . �✓ ........--• --- ,-�o ------`------------------------------------------------------�--........
-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental 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 p
Application Approved BY -: --------- - j �e�J* -------------------------------------------------------------- - ...d....%��
Date
Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------- -- -- ------
-- - - --------------------------.......................--------- ------------------------------------------------------------------------------------------------------------....................... ------.................................
PermitNo. ------ ........................ Issued --------------------------...--------........-------------ate-----
Date
THE COMMONWEALTH OF MASSACHUSETTS i
BOARD OF HEALTH
TOWN OF BARNSTABLE
C9Prtifirate of (gontpliatt.CP
THIS IS TO CERTIFY, That.the Indivi ual Sew;;ge Disposal System constructed ( ) or Repaired ( )
by � ''t�.5 S. --------------------------------------- s
� Installer
at ... .G'.�: L/ f............. --------1 ... .AW l",I....-----h.,.1. ...................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTE
DATEM WILL 6 C' ..TISFACTORY. Inspector `........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
qq TOWN OF BARNSTABLE
D�.... FEE..... ....0........................
Movalla irks Tunstru tiun f rrntit
Permission is hereby granted. .>_ 3 � h/S- =•.............................................................
to Construct ( ) or Repair (koT an Individual Sewage Disposal System
atNo................. r,,.... ..�� n�3 �' ! ....... ,4.......................................................
Street
as shown on the application for Disposal Works Construction Permit No,A�... Dated.........................................
............................... ----•---•--•••••--------------••--------------------•-----.
g �DATE............. 1 ......•-•---•----------•-•---
Board of Health
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
No..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_..or.............� ..�''..
.Pplirafun for Bhipaoal Workii Tnnitrnrtion Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at: aov�
ca Address a or Lot
..........
• •
w / Own A.es ...
..(...... ff........ ...... . ...... ......... ..... .. .... .............................................
Installer Address
UType of uildi Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) 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—Liquid capacity............gallons Length................ Width...._........... Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.--------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water____-_______--_-_-___-_.
f� Test Pit No. 2................milnutes r inch Dept of Test Pit-------------------- Depth to ground water........................
a+' --------- - -------- - ----------------------
•........
------
------------------
•-----------------
-••---------------•--
O Description of Soil................ ��
x
. -----
UW ----------------------=----=-------------------------------------------------------•- ...................................... --- .---- --- -------- ........
Nature of Repair or Alterations—Answer when applicabl_° '_ -- - •_-:---------------------•�•_.-
............. ---- - --- ---- e ••--a-------------•----•--------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article YI 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.
SigneI.................. ---------------------------------••---------...........----••-•---
Application Approved By----- � '�" !� - . at
`"
Date
Application Disapproved for the following reasons:.................................................................................................................
--------------------------------------------------------•--...-----••-•---•-----•--•-••-•-----•-•-•-----•-----------------•••--•-•-----------------•----•--------••••-----------...---------------......
Date.
Permit No. Issued..J.die// .2..
Da _/7
€e
e rer�
No r Fim. ..... ....... 4
THE COMMONWEALTH OF MASSACHUSETTS
ti
BOAR® OF HEALTH
Applirativit for Mfipviial jarkii (foutru4ion Prruid
Application is'Hereby made,for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
t '« °
`a... :..'vi6:.. ... '► Py9th° S9,a.vv. - § �.. r'�'- �* �!`� .... ...!s i° ......
Y Qca�-AddressB^ r > xq� or Lou46.
d *
8�, N. ....J o� ,pzya`+'+`.':r t yl' •+• .c am�' e..��t' ..............
77
Fel
Installer Address
QType of Buildir Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............. No. of persons....__...........__..__._--- Showers — Cafeteria
Other fixtures-._._ ....................... .`
Design Flow...............................: ....gallons per person per day. Total daily flow..............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No................
.:... Width.................... Total Length--_...--.. .. Total leaching area....................sq. ft.
5 Seepage Pit No---------------------- Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results 'Performed by............. = Date..--....................................
Test Pit No. 1................minutes her inch Depth of Test Pit------------------.. Depth to ground water..-.---..-------.--.----
Gi Test Pit No: 2................minutes�i.r inch Depth of Test Pit.---:--__.._-_.___•• Depth to ground water------------------------
----------
O Description of Soil------...... r �'1�"' , ; {
W .................- •-• •• ---•--•• -- -------•--------••--••--••. -- 1 . ...........................................................
Al
U Nature of Repair `or Alter a b s Ans er when apphcabl� �..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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 .. .. .- -•... ........................•-----.... .........
DatV
Application li Approved By "'x' °*r -
S -
• Date
Application Disapproved for the following reasons:. _____ ________• ......-• ...........------....................••-•.......•-•.._.............
------------------------------------•-------------------------------.........------------------------------•---•---------------------•--•-•--•----••.......•-------•-•---•----•••-•---•--••---••-••--••
Date
Permit No.. Issued . ...
Dafe '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
'..�a..'az' .................OF....,.. x,..F`s i. v a! Gi..' ...... " .... ..............
. Trrttfiratr nt Toutpha trr
t
THIS S�O CIRTIEY,,Th, Indtv>dual Sewage Disposal System constructed ( ) or Repaired ( ° )
Y v
r+ In t,el 3
has been installed in accordance with the provisions o icle XI of Tl ¢ State Sanitary Code desviibbed the
E
application for Disposal Works..Construction Permit No----------------- -__. .......... dated ":`, ., .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GyARANTEE THAT THE
SYSTEM WILL PPNCT19N SATISFACTORY.
Fa
DATE .. ` . � -,�� inspector.......... -----•-•----..
,ram k --.... .
THE COMMONWEALTH OF M'A55ACHUSETTS
BOARD OF, HEALTH
NO k* ft
.. FEE ib::
�� 1n r prt
Permission is hereby; granted �vpt�r' np i ...........................................................
to Construct ( ) or�iepair' (V.)'�tr"Individual S r age Disposal System
�' .'. J .... ..
at No
Street
d 4 q
as'shown.on the applica'tion.for Disposal Works, Construction erit>t No: s ` s ted ¢ ..
¢f z ,oar o Lf lit jv
DATE.... .. `':,. 3 ... �' ....... ...... x,
FORM 1255 HOBBS Fi WARREN, INC., PUBLISHERS
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