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0169 MEGAN ROAD - Health
,M_egan Road Hyannis A= 291-236 1 i 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 format 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1 st FI.,367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE:`_ 1 /aq, JaO I Lf Fill in please: ; APPLICANT'S YOUR NAME/S: i 1a No r(%C= 22r Q f-� °k� `` g y'k BUSINESS YOUR HOME ADDRESS: J G 11,1 1 v aC F, ry (2 x. 1� � C non„ �', rD,)6o� P. TELEPHONE # Home Telephone Number CS-a N)C)'82. NAME OF CORPORATION 0 O L-, of 67 'NAME OF NEW BUSINESS, TYPE OF BUSINESS �jL-_ r,�rV rV C IS THIS A HOME OCCUPATI N? YES - : NO ADDRESS OF,BUSINESS / - [Asses .. .'. w MAP.PARCEL NUMBER C r . 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 COMER'S OFFICIE, MUST COMPLY WITH HOME OCCUPATION This individu I hs n Inf of n ` ermit re uirements that pertain to this type of business. RULES AND REGULATIONS. FAILURE TO I h9rized . n, fe** COMPLY MAY RESULT IN FINES O MENTS: !� 2. BOARD O HEAL H This individual has been' rm�� of the permit requirements that pertain to this type of business. MUST xmy 1� I- ALL I, _ �U{� ,t-_4FAR OIJS MATERIA1.S IREG! Authorized Signature* 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: TOWN OF BARNSTABLE Date: 106114 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: d- BUSINESS LOCATION: —l- -T=C- Gc� Q(1 INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: G fj s? CONTACT PERSON: ; EMERGENCY CONTACT TELEPHONE NUMBER: 7-4 W a G g �c?y�-�j MSDS ON SITE? TYPE OF BUSINESS: rjc--!:�k ,,,i,v G INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals(Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) 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 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 4 C b �C Windshield wash I Sol WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applic 's Signature Staff's Initial Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Z� C, V1 Property Address Owner o 6; V1 information is t.J ll�//a ✓I Owner's Name required for every 'A✓1 i7/f !/L L Da`6 0l page. City/Town State Zip Code Date of rasped n Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your , cursor-do not �V use t ��� A✓ /l/ he return key. Name of Inspector LL/r/V/ o —T GH Company Name t-2o �b l� Company AddressZT 11_ City/rown O ^� State Zip Code Telephone Nu License Number B. Certification I certify that I have personally inspected the sewage disposals stem at this addre ss ess and that the information reported below Is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340,of Title 5(310 CMR 16..000). The system: : i Passes ❑ Conditionally Passes ❑ Fails :Z 4 ~� ❑ Needs Further Evaluation by the Local Approving Authority 4 t�� Inspector's Signature Date �r 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 floes not address how the system will perform in the future under the same or different conditions of use. 15ins•t vio rifle 5 Official Ins l Faction Forth:Subsurf e �°�8 System. 1 0l 7 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments e /?d Property Address Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of Vspe lion B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) :ste asses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 8) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the 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)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): i l5ins•11/10 Tille 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 lei Property Address S." /{ / to Owner Owner's Name information is required for every Al 6k✓)h/ page. Cityrrown State Zip Code Date 9f InspAction B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health).- broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ 'Y- ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines In accordance with 310 CMR 15.303(1)(b)that the system is.not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pegs 3 or 17 Commonweal.� th of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � �, Property Address l Owner Owners Name information is - l required for every page. Cityfrown State Zip Code Date of MPE n B. Certification (cunt.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must Indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ 9 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Eg/"" 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 ❑ f�—/ Liquid depth in cesspool is less than 6"below invert or available volume is less than Y day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name—/4 /• information is required for every G��/1 �/ Oub 0/ page. City/Town State Zip Code Date o Inspe ion B. Certification (cont.) Yes No ❑ 0-' Required pumping more than 4 times in the last year NOT due to clogged or —/ obstructed pipe(s). Number of times pumped: Elp 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. ❑ LJ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ 2/_ The system is a cesspool serving a facility with a design flow of 2000gpd- / 10,000gpd. ❑ L-�,/ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 151ns•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Dispose)System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address / vG Owner Owner's Name information is required for every rl✓l f f 0 page. citylrown State Zip Code Date of In pectio C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No �❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? L�' ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? /❑ Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? 8z0 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 example, a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): _730 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address C/ Owner Owner's Name information is /1�( O�6 0/ / ;711 required for every �%� page. CitylTown State Zip Code Date of Aspection D. System Information Description: Number of current residents: Does residence have a garbage grinder'? ❑ Yes ffNo Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ©moo Laundry system inspected? ❑ Yes ONo Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Y o /— Last date of occupancy: Cam!,Ile,,,T Date 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: 15ins•11/10 Title 5 Official Inspection Form:Subsurface a Dis �'+89 posa1 System•Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'y / V / ? Property Address Owner Owner's Name a information is /�jl required for every �'+✓��/ ZT 0116 O page. Cityrrown State Zip Code Date of(inspecOon D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: �� � T � Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy m: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): I5ins•11l10 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14& G ,� Property Address l./ '_� 4IvGV) Owner Owners Name information is �G Nritr � 0�60/ required for every _ page. City/Town C74 State Zip Code Date of IrApecon D. System Information (cont.) Approximate age of all components-,date installed (jiff nn)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 0-No Building Sewer(locate on site plan): �/ Depth below grade: feet Materia constructi;40 cast iron PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet �en f construction: concrete ❑metal ❑fiberglass ❑polyethylene .❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: X Sludge depth: 15ins•1 U10 - Title 5 Official Inspedbn Fortn:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2y /b A�'��G v1 Property Address Owner Owner's Name ' information is required for every G y1 f LI e�a b 0 page. Cityfrown C71State Zip Code Date of li4specti& D. System Information (cont.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle / Scum thickness L-2 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? o% �G Je li�L{_ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): u✓`1 t n' �0 7r {�i�—?�c'Z Gr � �rS �'f ✓i'1-e . �o�►d 7l pk! , Grease Trap(locate on site plan): Depth below grader feet 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: Date tslns.11/10 Title 5 Official Insp ection Font:Subsurface Sewage Disposal System•Page 10 0l 17 Commonwealth of Massachusetts - - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V1 Property Address Owner Owners Name information is / r A o L 6 o i required for every N 4� page. Citylrown State Zip Code Date of I spa ion D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•11/10 Title 5 Vidal Insp ection Forth:Subsurface Sewage Disposal System•Page 11 0/17 Commonwealth of Massachusetts -1-j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t n Property Address --CC4 111V'C,0 Owner Owner's Name information is required for every hlf page. City/rows State Zip Code Date o Inspe ion D. System Information (cont.) 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.): a del � L Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soll Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewege Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Jl/� //�v44 Pj Owner Owner's Name information is required for every page. CityfTown State Zip Code Date f I nspiliction D. System Information (cont.) v Type: leaching pits number. ❑ leaching chambers number ❑ leaching galleries number ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r�- Cesspools (cesspool must be pumped.as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Tile 5 Official Inspection Form:Subsurface Seyege Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address sci r7 Owner Owner's Name information is G 0 4 I f �'/ O�t7 0 required for every page. City/Town State Zip Code Date if Inspe ion D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Otlldal Inspection Form:Subsurface Sewage Disposal System Page 14 0l 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 0 Property Address SC 4 A Owner Owners Name information is �� required for every page. Cityrro`nn State Zip Code Date of Kispecdon D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: Rand-sketch in the area below drawing attached separately G 15ins-11/10 Title 5 OfWal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address C,y lvn✓1 Owner Owner's Name information is required for every page. City/Town State Zip Code Date f Insp lion D. System Information (cont.) Site Exam: /V ❑ Check Slope ❑ Surface water �✓ �d` I ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water a 7 feet Please indicate all methods,used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: /X9 r V V, � - S is dovL� Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage DDllsposal System Form-Not for Voluntary Assessments Z—� Ae G.-► Property Address Owner Owners Name information is / /�( O� required for every G�N/f , ./ 7` page. Citylrown State Zip Code Date o Inspe on E. Report Completeness Checklist inspection Summary: A, B, C, D, or E checked inspection Summary D(System Failure Criteria Applicable to All Systems)completed O'System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I5ins•11/10 rifle 5 Official Inspection form:Subsurface Semge Disposal System•Page 17 of 17 0 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS-NIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFORA'IATION(continued) Property Address: Owner: ehe�fw Date of Inspection: p$ 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. i a � O1 aa; lfol- dL.5 113 33 Q3 -32,1 Titlo tncnortinnC........ L/t:rinnn 1(1 CO-Al-MONIA-EALTH OF XDsSACHUZSETTS w EXECUTIVE OFFICE OF E_\7riRO-_,,ITENT-U Al DEPARTMENT OF ENVIRO-_,\7?VIENT L PROT_CTIO-\� c?� 9/ — o2 TITLE 5 OFFICIAL INSPECTION FOR-All—NOT FOR VOLUNT -R-Y ASSES VENTS ' SUBSURFACE SE`VAGE DISPOSAL SYSTE4I FOR:UI PART A } CERTIFICATION4. r� p = ' Property Address: 169 z�// a', lqd, a r►vi,t /� OoZ 6 a/ w ca Owner's Name: Owner's Address: o /'ems � co OaISS Date of Inspection: Name of Inspector: lease print)/ GrdK / o/se-A' Company Name: I_Wto F Mailing Address: v COZ /ate a A, Telephone\umber:CSo�? ) 'ys 77 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage.disposal system at this address and that the ir-Tormation re orted below is true, accurate.and complete as of the time of the inspection.The inspection.yas t}er owed based on :: training and experience in the proper function and maintenance of on site sewage disposal syst2tns. I am a DEP approved system inspector pursuant to SS ' n 15340 of Title 5(310 CMR 15.000). The 5,-ste-m: L� passes Conditionally Passes Needs Further Evaluation by the Local -kpproving Att orit Fails Inspector's Signature: Date: 1710�:2 The system inspector shall submit a copy of this inspection reporr to the Approyin=Authority(Board of i <o_ DEP)-,yithin 30 days of completing this inspection. If the system is a shared system or has a des_ n o.; of,1`'1CI�0 gpd or greater, the inspector and the system owner shall submit the report to the zp =opriate r.=a o-a1 o=t ce DEP. The original should be sent to the system oi:mer and copies sent to the buyer, 'appii.� I ano Ta authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at*ha time. This inspection does not address how the system wilt perform in the future under the game or di-erer:r conditions of use. V l� Title 5 Inspection Form 6/15/2000 G/v page 1 Paae 2 of 11 OFFICI_A.L INSPECTION FORIM—NOT FOR VOLUNTARY o TARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEI'I I,SPECTIO'\ FOR-NJ PART A �CERTIFICATION(continued) Property Address: / !L e; ,�&j Owner: eNe Z t ,� / Date of Inspection: Inspection Summary-: Check A,B,C,D or E/-ALWAYS complete all of Section D A. Syste Passes: I have not found an information which indicates that any of the failure criteria described _n 3'0 C\•IR 15.303 or in 310 CMR 15.3304 exist. Any failure criteria not evaluated are indicated belovv. Comments: B. System Conditionally Passes: /1/ One or more system components as described mi the"Conditional Pass"section need to be replaced or repaired. The system upon completion of the replacement or repair; as approved by the Board of Health. =11 pass. Answer yes,no or not determined(Y,N,ND) in the for the followina statements. If"not detemune ''please explain. The septic tank is metal and over 20 years old*or the septic tank(whether~fetal or no ) is stracturafl unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System wiil pass inspec•on if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a C;ertifiCate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due-a reke.i o. obstructed pipe(s) or due to a broken, settled or uneven distribution box. System v611 pass insre: ;or if(.:ia 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 broker_or obs�tr:cted nice;;s}. , pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEl7INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 169 r Owner: 610a Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to der--rive if the s -s:em is failing to protect public health; safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 Cl1R 15.303(1)(b)that the system is not functioning in a manner which will protect public health.safety-and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or pri`-y is within-50 feet of a bo_dering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public`eater 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 die SAS is tV n 100 feet of a surface water supply or tiibutary to a surface water supply. The system has a septic tank and SAS and the SAS is within.a Zone 1 of a public.ya-!r supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water suppt t=;ell. _ 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**. 'N2ethod used to determine distance **Thus system passes if the well water analysis,performed at a DEP certified laborato_ for colifo; bacteria and volatile organic compounds indicates that the well is Zee from pollution ftom that faci: 1:and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than pprn, pre:-id.d fha--o o-^er failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE�1 INSPECTION FORM PART A CERTIFICATION(continued) Property Address: / /��2 G R( cl—tz�'1! Owner oee An. Date of Inspection: D. S-%-stem Failure Criteria applicable to all systems: You must indicate "yes"or"no"to each of the follov<ing for all inspections: Yes �o _ ackup of sewage into facility or system component due to overloaded or clogged SAS o- ess,:)oo L/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload.-,-- or /clogged SAS or cesspool V StatiC liquid level in the distribution box above outlet invert due to an overloaded or clogged _-�,S or esspool Liquid depth in cesspool is less than 6"below invert or available volume is less than i` day _Required pumping more than 4 times in the last year NOT due to clogged or obst-acted f times pumped y portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 fret of a surface water supply or tributary to a surface water supply. ny portion of a cesspool or privy is within a Zone 1 of a public w-ell. portion of a cesspool or privy is within 0 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 xvater supply well with no acceptable water quality analysis. [This system passes if the«-ell water anah-sis. 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.] (Yes./lvo)The system fails.I have determined that one or more of the above failure c ineria- ist as described in 310 CMR 15.303.therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10.000 gpd to 15.000 °gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) es no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim_Wellhead Protection-A-ea Zone II of a public water supply well If you have answered"ves"to any question in Section E the system is considered a significant h e=t. or -;•:;e- "yes"in Section D above the large system has failed. The own, or operator of any large significant threat under Section E or failed under Section D shall upgrade the svSte m ac o,d.- e 15.304. The system owner should contact the appropriate regional office of the Depa.men,. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY _-SSESSNIEoTS SUBSURFACE SEN AGE DISPOSAL, SYSTEM INSPECTI®- FORAT PART B / CHECKLIST Property Address: (� � � �t-7 Ny}t Owner: Ve�IEZ<< p a/� Date of Inspection: 7 )- Check if the following have been done. You must indicate"yes"or"no"as to each of the fol'1•ovvinC: Yes �o Pumping information was provided by the owner,occupant..or Board of Health 1 Were any of the system components pumped out in the previous two 1;eeks v Has the system received normal flows in the previous t«To week period v 1-3a`e large volumes of water been introduced to the system recently or as part of iris insoectio^ Were as built plans of the system obtained and examined?(if they were not available ?zote as\ ) Was the facility or dwelling inspected for signs of sewage back up ' Was the site inspected for signs of break out? Were all system components.excluding the SAS;located on site Were the septic tank manholes uncovered. opened;and the interior of the tank i lspe tee fort_e coneitiat 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 1z th in-ormation on e roper maintenance of subsurface sewatre disposal systems? The size and location of the Soil Absorption System(SAS)on the sire has been dote-pined ba-Sed on: Yes no Existing information.For example; a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part Cis at issue appro-dmatior_� e=e is unacceptable) [310 C_MR 15.302(3)(b)] Page 6 of 11 OFFICIAL I.i°SPECTION FORM—NOT FOR VOLUi ''TARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'TION FOR_NT FART C SYSTEM I\FOR_NZATION Property Address: / 9- �e �e�ezOzr-ner° tF v Date of Inspection: 3 �' O«'CO1NTDITIONS RESIDENTIAL. �Number ,�- of bedrooms(design): Number of bedrooms(actual): DESIGN floe-based on 310 C_'v4R 15.203 (for example: 110 gpd x of bedrooms): Number of current residents: O � Does residence have a garbage grinder(yes or no):A'° O' Is laundry on a separate sewage system(yes or no)Y� [if yes separate inspection required; do 7 Laundry system inspected(yes or no): Seasonal use: (yes or no): G1 4el Water meter readings, if available(last 2 v_ears usage(o-pd)): Sump pump(yes or no): /moo Last date of occupancy: C 0 NEVI ERCIAL/INDU STRIAL Type of establishment: Design floe,(based on 310 CVIR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings. if available: Last date of occupancy/use: OTHER(describe): GENERAL,INFORMATION Pumping Records Source of information: /luw,rle�i � za'�'r_ 0G--� Was system purrTed as part of the inspection yes or no): If yes,volume pumped: gallons--How was quanrir<,pumped determined? Reason for pumping: TV OF SYSTEM _Septic tank; distribution box. soil absorption system _Single cesspool _Overflow cesspool _P-ivy _Shared system(yes or no) (if yes, attach previous inspection records; if anv) _Innovative/Alternative technology.Attach a copy of the current operation and ra ntenan ce on„ac i i-o obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): ' Approximate age of all components; date installed(if known)and Boy ce f ulfor.-a on: Were sewage odors detected when arriving at the site(yes or no):,tb Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR V PART C A SYSTEM INFORMATION(continued) Property Address: /'�� Cc✓1 �� Owner: Date of Inspection: 3 BUILDING SEVi'ER(locate on site plan) Depth below grade: Materials of construction: cast iron _0 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK:_(� locate on site plan) Depth below grade: Material of construction: oncrete_metal_fiberglass�olyefdvlene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(a<<ach a copy of certificate) y Dimmensions: S'XSludge depth_ Distance from top 4f sludge to bottom of outlet tee or baffle: Scum thickness: /I` Distance from top of scum to top of outlet tee or baffle: // Distance from bottom of scum to_boat rt of outlet tee or baffle: How were dimensions determined: A/e Ag, --PZZ//1C-r— Comments(on pumping recommendations.inlet d outlet tee or baffle condition; structural, teg i , lieItnid e eL as lated to outlet invert.evidence of leakage. etc. : . �n� n i4 4 V /11 7111lM$r /.r.w4i- avid G¢�?�el /✓1 vo r <roq. /lam GREASE TRAP:N (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(on pumping recommendations. inlet and outlet tee or baffle condition structural new; icu_d :e as related to outlet invert; evidence of leakage; etc.): Pave 8 of 11 OFFICIAL.. INSPECTION FORM-NOT FOR VOLUNT_3RY ASSESSNIENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FOP31 PART C Q SYSTEM INFOR-NZ TION(continued) Property address: 0-,vner "La aI22 n Date of Inspection: 3 TIGHT or HOLDING TANK:/6"� (tank must be pumped at time of inspection)(locate or_site plan i Depth below grade: Material of construction: concrete metal fiberglass polyethylem mher(exulair): Dimensions: Capacity: gallons Design Floe: —gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(;yes or no): Date of last pumping: y Comments(condition of alarm and float switches;etc.): DISTRIBUTION BOX: /V (if present must be opened)(locate on site plan) Depth of liquid Ie:-el above outlet invert: Comments (note if box is level and distribution to outlets equal,any evidence of solids cam over, any of leakage into W out of box. etc.): r`o ne pvA arS ,�4,AI- 4_0 me Loc 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.): I T;tlo Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS:1HNTS SUBSURFACE SEdVAGE DISPOSAL SYSTEM INSPECTION FOR_lt PART C / SYSTEM INF/O�R/R'\'IATIO\'(continued) Property Address: Owner: eble,ZiG Date of Inspection: 2-.T SOIL ABSORPTION SYSTETIN7(SAS): (locate on site plan,excavation not required) if SAS not located explain why: Type leachins pits,number: leaching chambers. number: leaching galleries;number: �/ r�j-0 y e leachin_tr trenches; number,length: leaching fields, number, dimensions: 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 v ege a on. etc.): d1s oIq rR� iG L/ CESSPOOLS: A (cesspool must be pumped as part of inspection)(locate or,site olan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow-(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition o .-egetarior_. ctc.l: PRIVY":/V (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 e_ctaTo Pate 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUT'T_ARY ASSESS-MENTS SUBSURFACE SEWAGE DISPOSAL SYSTE'iI INSPECTION FORT PART C SYSTEM I 'FOR lATION,conr-nuecl Property address: 9 Owner: kepleki, h o Date of Inspection: 0�3 SKETCH OF SEWAGE DISPOSAL SYSTENI Provide a sketch of the sewage disposal system including ties to at least two permanent re rence lar_drlar'�s or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. O G - as ��- 31 „ Q3 -3A - Ti�lo � Trcr�ontir�n Cnr..� G;1[/^innn 1!1 F • r Page 11 of 11 OFFICIAL, INSPECTION FORli1-NOT FOR VOLUNTARY"ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORAIATION(continued) Property Address: /6 e �� Owner: ke,'-CZt Date of Inspection: 3 D� SITE EXAM Slope Stuface water Check cellar Shallo,x wells O�0 Estimated depth to a water ater a y feet Nf Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design.plans on record-If checked, date of design plan re vie«ed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked ;vith local excavators,installers-(attach documentation) Accessed USGS database-explain: You mus 'esc e how you estab ; d the hi h arouund water elevation: 0 tJli l lam+T �b O 0 h✓ 11'.. N GC, S. ._r i f OvL- , Ti+lo T_c .,+;__ C.___ L 11 z I,_ No._.. r_.._.. FEa ........................ LTH H BOARD AOF F�HEA CH H TSB �^ 2 1� :._..........OF...7. ... 1 Appliratinn -fur Uiipu. ial Works C onstrurtion Prrinit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at fit. G .C!f ' _ -------- ------------------------- ,� Locatio dress .- or Lot No:- nor Address W a ......... •-------------•• - ----- •---•---------------- ----------------•-•••-••-•-------••------•------ Installer Adddrr ess Q Type of Building Size Lot... _�+�_��_Sq. feet U Dwelling—No. of Bedrooms_______________ _-___Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ________________________'_-- No. of persons_--____-_________________- Showers ( ) — Cafeteria ( ) W Other Lxwres --------------------- .. W Design Flow.......... per person r day. Total dai flow_____________ _______-.-__._._gallons. WSeptic Tank—Liquid capac�,,allons llons Length___________ .......-...._._.. Diameter___.....__.____ Depth_____.__..__. x Disposal Trench—No. ___ _______________ Wi h___•______ ________ Total Length____ .:......._. . Total leaching area--------------------sq. ft. Seepage Pit No.._______ __ e .._.__ _ _ ._ o i Total leaching area-_�'-C __ ,sq. ft. z Other Distribution Dosing tank aPercolation Test esults Performed bY --------------------------------------------------------------- Date_..--_-----------------------------.. Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water.._-_____.__.__----__--- w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__.__-_____.___-_____-_. 9 ----------••----------------------------------------------------------------------------------•............................................................. Description of Soil ---------- x x ------------------------- ....... ------- -------------------------------•--- U Nature of Repairs or Alterations—Answer when apj icable........................................._------------------------------------------------------ ------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------- --------------- 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 be issu by the bo rd of health. ✓�g A �i �s��� t ned--- -- ------- ------- Date Application Approved By.__..::.. . ..---....--- F -------- Datefi' Application Disapproved for the following reasons:------------------- ---------------------------------------------------------------------------------------•-•-•--...-----------•-•-•--•----•--------......--....__......_......--------------------------...---------.----- Date Permit No. Issued._... -��7� ------ Date --------------------- r No.._ ..... Fsa. rt.....V...... THE COMMONWEALTH OF MASSACHUSETTS �+ BOARD OF HEA L7T H :... ..........QF:......- ...&_.-. .._............................... Appliratiuu -fur Di,tipuitt1 Murko Tonotrurtiuu Puri t Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at ... Locatio 7Aildress or Lot No. O .. Address - - - - -- -- - - Installer Address / UType'of Building ? Size Lot....lt}._���__—Sq. feet Dwelling—No. of Bedrooms---------------____-_______-__-.__..._-----_Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building --_-..-..-__--------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) ! da Other�tl�res -------------------------------- - C�� ------------------- ---------------------------------------------------------------------------------------------- Desi n Flow........... ............................. Mons per person per day. Total daily flow--_--_-___-----_ _ "�� W g - - g• P P �' Y• �Y -------------------------gallons. .4 R; Septic Tank—Liquid capacix6> Ugallons Length---- __........ Width- .-__... Diameter---------------- Depth---------------- Disposal Trench—No... _ y h__-:_-_-__-•�------ Total Length----_i_---_____._ _ Total leachingarea--------------------sq. ft. { ;. Seepage Pit No.___.. __ Di�ame ._ � e 1!li be o t et _� Total leaching trea._�4 ?2:_.sc. it. r or fU �`'p g< 1 I z Other Distributton�bdx O Dosing tank ( a Percolation Test Results Performed by-----------------------------------------------------------------•----•--- Date................ ---------------------- Test Pit No. L_______________minutes per inch Depth of "Pest Pit-_.--_.-___-______-- Depth to ground water.----------------....... !_, Test Pit No. 2..........::....minutes per inch Depth of Test Pit-------------------- Depth to ground water------------- -.___. _ ......................................................... ODescription of Soil --- ----------------------- ------------•------------------------------------- -�,---------- ------- --------------------------------------------- x �., ------------------- --- ---------- r ----- --. -- ----------- --- ---------`--- ---- -----------------------"= -------------- ------------ --- - •------- -------•--•-- ---- ----- -----------------•-;----- V Nature of Repairs or Alterations—Answer when applicable .----_- -.-_ ,----------------------------------------z.- ------------............... `. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 issu by the board of health. - - igned-- ` `� /tea /.��y-�,' - ✓ -. `�!`__��7'7 r�. ate Application Approved BY late Application Disapproved for the following reasons:................................ -- -•---.....---...----•-•-•-•---•------------•-•----•-------....._----- --------.•-------•--------------•-----------------------' -= t' Date Permit No----------------........................................ s Issued----- a_1 3 Date ti THE COMMONWEALTH OF MASSACHUSETTS ' BOARD F HEALTH ,. ..... of ,. �, -yam.. ; f4.. ................................. --..�,d� �: Cnrrtifir�t� of �unt��ittnrr . THIS,j,Sf10 CERTIFThat-tkt'e Individu SewageAtDisposal System constructed ( or Repaired ( ) ... _ a � y has.been installed in accordance'with the provisions Hof Article XI of The�State Sanitary Code as describe in the application for Disposal Works Construction PPnit�o------------- - dated_.._._ .__ >•, ` . THE ISSUANCE OF THIS ICEgTIFICATE S ALL NOT BE CONSTRUED AS A GUAR�NTEE AT THE SYSTEM WILL FU CTION',`SATISFACTORY DATE__v9*/ad. .7..,y-�----------------------'----i-------------•-- Inspector -- - "" ..............-- THE COMMONWEALTH OF MASSACHUSETTS BOARD O,-F HEALTH. - �iti�u,�tt;1.� urk,��u�,�tr�trtiuit rrutit Permission is hereby granted----- -'�--tc'`-' .='^ �-�,-�` •-- - --------------•...-•----------•....------••. to Construct '(�or Repair ( ) an'Itidividual Sewage Dt posal S stematNo •:f -..�._._.._j �_.._.---•• l - - Street / as shown on the application for Disposal Works Construction Pe yn'i No_______ __ ____ .......12;?. P10" r .. . cz• • r r,, • � Board of Health DATE----------------------------------------------.......--------------------------- �• I FORM 1255 .HOBBS & wAR&6,i` INC.. PUBLISHERS - • .. sue, •� Assessor's map and lot number .............. .............. . ......... C: - Sewage Permit number ... .. .. �oF THE roe rr TT N OF A R.N S H. A B L E Q � 1639- i B9HIISTdDL : BUILDING APPLICATIONFOR PERMIT TO ..�. .L.�-. ....... ... ........ ...... ....................................................................... TYPE OF CONSTRUCTION ........ ..�...... .... .` t'. .1 ` .................. ................ ......... ................................ 'G< / ..............19.a. TO THE INSPECTOR OF BUILDINGS: The undersigne hereby applies for a?permit accordin(t to the following information: r �6 ,� Location ... .... r ���` �:�-. .. .............. ... .�:!c�.....'�'N'`.......�......................... ......... ✓f r li Proposed Use .., 1 � ............................ ....... .... Zoning District ... ..................................................Fire District .......,.....:: 't�!!! `.L..................................... .j......... L� Cr� -c �s ........ . .......`""'!" -7� Lr�/'��' �x•� .. �T .........Address Nome of Owner . .... . .................:.:.... f"�.. Nome of Builder ..... ..`. . .......Address Nameof Architect .... .................................................!.. . . ....Address . ,................... ......................p....................................... ... ........ . . .. .. . Foundation G:....�,..:'........ Number of Rooms ....... �......................... . . . ......................................... ....... i Exterior .�Rf`Y�-Z� ..'.......::'�'.�.....f.....................:........Roofing ..��.!�Ifj�L.�. ........ . .......... . ........................... / ��.fittiG�C ...............Interior ......1....... FloorsG1 . ........................................ :......................:........................................... y ,Z Heating . .......1:11 .. .. .. -:L' d r f j� . . Fireplace ............../...................................................................Approximate Cost ......... "...:....�� ............................... Definitive Plan Approved by Planning Bacrd .� ____._.__.. _19 Area ................................. ....... Diagram of Lot and Building with Dimensions Fee ....:........................................ SUBJECT TO APPROVAL OF BOARD OF HEALTH ' . I r •t t Ar, t t> l hereby agree to conform to;/all the Rules and Rec;ulat ar.s of the Town of Barnstable regarding the above. construction. Nome ....._.. . .......... {�. ........................