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HomeMy WebLinkAbout0188 MEGAN ROAD - Health 188 PY1 Eta HYANNIS 4 A 291 263 i i i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15, 2013 required for every ry page. City/Town State Zip Code Date of Inspection 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 David D. Coughanowr, R.S. use the return Name of Inspector key. Environmental Company N Company Name 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address 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 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10--t 0�' P" � January 15, 2013 Inspector's Signature _ Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l5ins•11/10 Title 5 Official Inspec n rm:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15 2013 required for every y ry page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) 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. 1 *A metal septic tank will pass inspection if ifis 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): t5ir.s•11110 Title 5 Official Inspection Form: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 wM 188 Megan Road Property Address William P. Harran Owner Owner's Name information is rY Hyannis MA 02601 January 15 2013 required for every y , page. City/Town State Zip Code Date of Inspection 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 ' i Commonwealth of Massachusetts ` W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15, 2013 required for every y ry page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 Backupf sewage into facility or system component due to overloaded or El ® o clogged SAS or cesspool Discharge or pondin of effluent to the surface of the round or surface waters 9 9 9 ❑ ® due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15 2013 required for every rY page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 II 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. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'wM 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15 2013 required for every y rY page. City/Town State Zip Code Date of Inspection 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? ® ❑ Has the system received normal flows in the previous two week period? El Z 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? p 9 ® ❑ 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? ® ❑ 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: Z- ❑ Existinginformation. For example, Ian at the Board of Health. P � p ® ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd 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 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15, 2013 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 128 gpd 9 ( Y 9 (gpd)): Detail: 2012, 2013 Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial 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 i Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15 2013 required for every y ry , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: occupant 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 System: ® 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/Alternative 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): t5ins•11110 Title 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 M 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15, 2013 required for every Y ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 11+ years. Certificate of compliance for new leaching gallery was issued 7/3/2001 (Permit# 2001-377 at Health Dept). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of 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: 8.5 x 5 x 6- 1000 gallon tank Sludge depth: Bin t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 188 Megan Road 1 Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15 2013 required for every y ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? previous inspection report Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time. Maintenance pumping is recommended within 2 years and every 2�ears thereafter. Tank and tees appear structurally sound and functioning as intended. Grease Trap (locate on site plan): Depth below grade: 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis . MA 02601 January 15 2013 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 x t5ins•11110 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 Janus 15 2013 required for every y January page. City/Town State Zip Code Date of Inspection D. System Information'(cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet inverts 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.): D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leaching gallery. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15, 2013 required for every ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 2 ❑ 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.): Soils above leaching galleries appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 8 inches below the top of the peastone layer. 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._ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15, 2013 required for every ry page. City/Town State Zip Code Date of Inspection 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts T 'tle 5 -fficiaa Inspection F®rrn o 'Subsurface:Sewage Disposal.System Form--Not for voluntary Assessments, ti 188 Megan>'Road Property.Address .William P. Harrari. _ Owner Owner s Name; .information is required'for every Hyannis _ MA 0260:1. Janus"ry 15, 2b13: page:, City/Town: State Zip Code; __Oate;o Ampecfion ' D. S'ystem Cnfor-- On {coat Sketch Of'Sewage Dmsposal 8ysten Provide.a view of tle;sewage disposal system, including ties to at1east-two'perrnanent reference landmarks or benchmarks Locate all'wells,with'in 100 feet:_Locate: where public water supply en#ers the building Check one of the'boxes below hand sketch in.the area,below; drawing attachedseparately is 2 � VA° Z" -+�,�:. t6lns 11C10' _ TdIe.5 0fi cial Inspection Form:Subs6666 Sewage Disposal System.Page 15 af'37 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15 2013 required for every Y rY page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 26 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: Previous inspection report ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Previous inspection report of 5/17/05 indicates leaching is 20 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 188 Megan Road Property Address William P. Harran Owner Owner's Name information is Hyannis MA 02601 January 15, 2013 required for every y rY page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 YOU KNISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: zo Co Mw Fill in please: APPLICANT'S YOUR NAME: L-O �I� M fran R Y h BUSlNESS YOUR HOME ADDRESS: J 8'8, W12cen y� .' tt TELEPHONE # Home Telephone Number NAME OF NEW BUSINESS VOL TYPE OF ESS S IS THIS A HOME OCCUPATION? +! YES NO Have you been given app'roval'from the building division? YES. NO c ADDRESS OF BUSINESS MAP%PARCEL NUMBER- When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business.. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has bpipn inform;eo of t mit requirements that pertain to this type of business. sties uth size Signature** COMMENTS: . d O DL t� 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: A C A bo vc BUSINESS LOCATION: n^- aV% I yan n i 5 ; d"`a , oq uo I INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: 50 - 2 1 I-510 1 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: L, n Ac Serzae y INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED the Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) —�— Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS COMMONWEALTH OF AWSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ST A Gv! /?d 0 p/ Owners Name: �it/�' tir�a v� C) Owner's Address: 8 f Date of Inspection: GN�I S 9 O� 60 c Name of specton pant) r l-e C) Company N , Mailing Address: c�- Telephone Number. CERTMCATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the'below is true,accurate and complete as of the time of the' information reported training and experience in the proper fimctice and won'The inspection was performed based on my approved system inspector pursuant to on 15� s 31 CMX 11�disposalof on site smge I am a DEP Pass�•s Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: °tee Date: 5 s Ile system inspector shall submit a copy of this inspection report to the Approving Autho DEP)within 30 days of completing this inspection.If the system is a shaved rjW (Board of Health or gPd or greater,the inspector and the system owner shall submit the or has a design flow of 10,000 DEP.The original should be sew to the report to the appropriate regional office of the authority. system owner and copies sent to the buyer,if applicable,and the approving Notes and Comments ' ***Thh report only describes conditions at the time of' econ and under the conns of use at that time. This inspection does not address how the system conditions of use. will peorm in the future tinder the same or different • Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A p CERTMCATION(continued) Property Address: 0 W 9,/ Owner. G� c, Date of Inspection: 9 p Inspection Sammary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 13.304 exist.Any failure criteria not evaluated are��below. Comments: a/ Sy 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. Answer yes,no or not determined(Y,N,ND)in the f explain. or the following statements.If"not determined"please The septic tank is metal and over 20 years o1d*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infltration or exfiltration or existing tank is replaced with a c0 tank approved ed by is System will pass inspection if the complying septic tank as •A metal septic tank will pass inspection if it is structurally sound,��Board of Health indicating that the tank is less than 20 years old is available. leaking and if a Certificate of Compliance ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed H approval Board of Health)•bm)oen,settled or uneven distribution box. System will inspection if(with broken pipes)are replaced obstruction is removed distnbation box is leveled or rephaoed ND explain: The system required pumping more than 4 times a year due to broken or obstructed piPes).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �� Ie ',�:rvq )?C-i Owner. ✓Y Date of Inspection: g p C. Further Evaluation is Required by the Board of Health: _L/Conditions cog which require further evaluation by the Board of Health in order to is failing to protect public health,safety or the environment. determine if them 1. System will pass unless Board of Health determines in accordance with 310 CMR 11303(i)(b)that the system is no functioning in a manner which will protect public heahb,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 Z. System win fail unless the Board of Health(and Public Water Supplier,N 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 **Thus system passes if the well water analysis,Performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is fime 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 Wm criteria are triggered A copy of the analysis must be attached to this form 3. Other Page4ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTMCATION(continued) Property Address: l YU Owner: & Date of Inspection• D. System Failure Criteria applicable to all systems: You mug indicate"yes"or`ne to each of the following for an inspections: Yes No/ �/ Disdhar�� geo facility ar system component due to overloaded or clogged SAS or cesspool ponding of effluent to the surface of the ground or surface waters due to an overloaded or gged SAS or cesspool ko Static liquid level in the distribution box above outlet invert clue to an overloaded or clogged SAS our 1 lagW depth in cesspool is less than 6"below invert or available volume is less than%day flow Req&W pumping more than 4 times in the last year NOT due to clogged or obstructed pipe()Number o times pumped AW portion of the SAS,cesspool or privy is below high ground water elevation. .rG Any portion of c=P001 or privy is within 100 feet of a surface water water suppt,, supply or tdbuutary to a surface portion of a cmipod or privy is within a Zone 1 of a public well. 'z Any Portion of a cesspool or privy is within 50 feet of a private water supply well wit-LZ AM portion of h or privy is less than 100 feet but supply well. private water greater than 50 feet from a performed at a D�e water quality analysis, MUS system passes if the well water analysis, certified laboratory,for WHOM bacteria and voladk organk compounds indkates that the wen is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S Ppm,provided that no other failure criteria are trfgered.A copy of the analysis must be attached to this form.] (Yes/No)The system W111.I have determined that one or more of the described in 310 CUR 15.303,therefore the system fails,Theabove n"fnj s ��exist e Health to determine what will be system° shoWd contact the Boa of necessary to correct the failure. L Large Systems.. To be corer a large system the system most serve a faciht3,with a design flow of 10,000 gpd to 15,000 gP� You must' 'cafe either-yW or`W to each of the following: (The follo criteria apply to large systems m addition to the criteria above) Y the system is within 400 feet of a surface drinlang water supply _ the m is within 200 feet of a tributary to a surface ddniang water supply _ _ the system Mated 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 1`yes"in Section D above the large system has failed The owner or operator of large ,or answered cant �3' m gnrfi threat under Sectionstem system considered .i.5.304.The system owner should contact approp�te regional officef try 314 CUR Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: / ?4,�f �e i Owner: Gr✓"u-1 Date of Inspection: Check if the following have been done.You most indicate`yee or"no"as to each of the following. Y"o /Pumping information was provided by the owner,oocupe11t,or Board of Health v Were any of the system components pumped out in the previous two weeks Has the system received normal bows in the previous two week period ✓Halle large volumes of water been introduced to the system recently or as part of this inspection J Were as built plans of the system.obtained and examines/ (If they were not available note as N/A) T Was-the hc&W or dwelling inspected for signs of sewage bade up Was the site inspected for signs of break out ✓ — Were all system components,excluding the SAS,locxW an site Were the septic tank manholes uncovered,open,and the mft=of the tank inspected of the or teem material of conduction,ems,�of d�h for the coition � �' slue and depth of scum _ was the fatality owner(and occupants if different from owner)provided with information on the m oe ofs�uface sewage�disposat�cma. pro The sue and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no — — xrsttng infbrmatioa.For example,a plan at the Board of Heahh. _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)P 10 Cha 15.302(3xb)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: ,t RC/ tf Owner. Gtlran Date of Inspection: _0 j k6'I.O CONDnWNS RESIDENTIAL Number of bodrooms(design):l Nor of bedrooms octu ) .DESIGN flow based.on:310 CMR-15203(for cxampie: 110 gpd x#of bedroomsr --75�9 Number of current residents: OZ—_ Does residence have a garbagp grinder(Yes or no):/V� 1s laundry on a separate sewage system(Yes or no),—ff [if yes separate inspection required] Laundky system (yes or no):Ll/� Seasonal use:(yes or no)._ Water meter readings,if/vatiable(last 2 years usage(gpd)): Sump pump(Yes or no): � Last date of occurpaQcy. 7,�117e- ► COMMERCIALMDUSTRIAL Type of establishment: Design flow(based on 310 C M 15.203): mod Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tang present(yes or no):— Non-sanitary waste dischwVd to the Title 5 system(yes or no):_ Water meter readings,ifavailable: Last date of occupancyhm- OTHER(desczibe): Pumping Records GENERAL INFORMATION Source of information: —pf d Q cc — ©C✓v%e.r Was system pumped as part of the inspection(yes or no):1,:ifV If yes,volume pumped:_pllons—How was quantity pumped determined? Reason for pumping: SYSTEM tardy distn'bution box,soil absorption system _Single cesspool _Overflow cesspool _Privy --Shared system(Yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the carrezzt operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of alb cxm}poNSA date installed(if known)and���P infornzatio Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM ENFORMATION(contimxod) Property Addrear. U U P Cc vi -RC21i Owner. Date of InspeChor. 9 0 BUILDING SEWER(local on site plan) Depth below grade: C)1) Materials of consbmct=_ iron —14 PVC otha( : Distance from private water supply if I snctioa lE . Commeft(an condition of joims,v evidence of leakage,etc.): SEPTIC TANK: —/ ;�►sac phm) Depth below grade: Material of construction:_oonci+ete—.metal iberglass._polyetgyiene —lother(explain) If tank is metal list age:_ Is age confirmed by a Certificate of cermcaft) g/ � (yes or no):_(attach a copy of Dimon- Shift Distance lop shidge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum.to D �to�a�'outlet tee or�a-1e � / How were Ow determined.• �'o/c &4 S CeC-,fr;C._— Comments(on pumping recommendations,inlet and outlet tee or baffle condi as to outlet invert,evidence of leakage,. ); ion'Muralth',liquid levels ��j / �lJS �1 ✓"!�� Gfvr Gvi j /h 00 0+� io /t/D .e 44, GREASE MAP;::(torte on site plan) Depth below grade:— Material of contraction:—concrete metal— _polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or bate: Distance from bottom of scum to bottom of outlet tee or baftie: Date of last pumping Comments(on pumping recommendations,inlet and outlet.tee or bate condition,strucpual u te",liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DLSPOSAL SYSTEM INSPECTION FORM PART C ,p SYSTEM INFORMATION(continued) Property Address; �0 2e, ct vi 41 Ownes: G/�a &LC4W Date of Inspection: TIGHT or HOLDING TANK:Z ttank must be pumped at time of inspectionVocate on site plan) Depth below grade: Material of construction con=ft metal fiberglass_-po1YethY1ene other(explain): Dimensions: Ca1acihr. Patton Design Flow: gallons/day Alarm p um(yes or no): Alarm level: Alarm in working order(yes or no): Date of last purring: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:Z/✓"t S Z_ Comments(note if box is level and distribution to outlets equal,any evidence of solids leakage or of bo ): / carryover,any evidence of O �ve/, So/c,ls- ll/© G PUMP CHAMB '' :L"('Iocate 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.): Pap 9ofIt OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSES3NOWS SUBSURFACE SEWAGE OiSPOSAL SYSTEM INSPEMON FORM PAWL. , SYSTEM EVFORMATION(oontimm* Property A&km ! /�eeq Owner. /T�rr�ar Date of Inspecdwm 0 SOIL AB80RT['MM MTEM{SAS): (Iorafr nt.ait�Plan,ercaiv:tioa�t r If SAS not located oV4M why: h Type " kaChing 4Sx to X � , ox10 x f ,1 : �o , : F ovanow cesspool,nnmbw. ve systm Typdttamco(tWhnojW ( C. (Wade coon of soil,signs of hydraulic Endue,lev/el of pending,damp soil,condition of vegetation, DV e- v� c' ©� ClPGvi Q0(2 C/ AVIO Ail �` n1tLlit be pompOd as pmt of' mspectiom)0ocate on site plan) Numbuandco : Depth—ref fiWdto inlet fimat: Dcpdiaf saft kg= Depth of==bMw Dim of cesspool: Materals of : Indication of g mundwatra MOW(Yea or n0): Comments*L'zondam of sod signs of hydc2dw Vie,lei of ponclisg oonfton of vegetadon�etc. PRIM:�lft an side plan) MakDime Depth ofsofi&� Cow*Wconftmoff,*m of c hffwe,level of p condition of vegdaro$etc.): • Page 10 of I I OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(c�d Pn)perly Address: Owner. 110 h Date of Iuspecdoa: 9Vi1 0 r SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system hwhding ties to at least two perms reference landmarks or benchmarks.Locate all wells within 100 feet Locate where public water supply enters the hgkhug v Ad 1a y , '43- Y 9 p� a o, / r -A �. Page 11 of I1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION(continued) Property Address: Owner. 1(rm V191 '¢ Date of inspection: SITE EXAM Slope surface water Check cellar — 0, Shallow wells ' D� Estimated depth to ground water a feet C©,,4-o v'- Please mdWe(check)all methods used to determine the hiopu and water elevation: Oitaned firom system design plans on record-If checked,dfe of design plan reviewed: Observed site(abutting PmPerty/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 haw you established thehigh,grnaad water dev p , O G� C. l�lG N�6�✓ fir n •,S�o �/ rq i' CF g 137 TO /:11 a ' 0 C7- �✓ a / TOWN OF BARNSTABLE LOCATION 'Z& �� SEWAGE # Q l — 27 VILLAGE' [. c 3 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 10 U 6 tic„L LEACHING FACILITY: (type) 2 33 D C.�AccS (size / . 3 NO. OF BEDROOMS _ D90 X 16.3 W x oZ BUILDER OR O `A OWNER �V �.rCCV% l PERMITDATE: k COMPLIANCE DATE: :7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within200 feet of leaching facility) A-PA Feet Edge of Wetland and Leaching Facility(If any wetlands exist ,p within 300 feet of leaching facility) A t Feet t} Furnished by S i s y to J p .r N No. 7 1 Fee �✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for 33iopazal bpotem Construction Permit Application for a Permit to Construct( )Repair(4)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(�J� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system. in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by this Qoard of Signed A Date Application Approved by Date J_ 6 Application Disapproved for the following reas&s Permit No. Date Issued 10 No. vee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes Zipplicatiou for 33igpogal 6pgtem Conotructioi Permit Application for a Permit to Construct( . )Repair(J)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ! _ Location Address or Lot No. \G f Owner's Name,Address and Tel.No. Assessor's Map/Parcel I s y `� d5 i - fit,3 . Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. CIO I Pk r--P- Si Cam- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank P V t S 1(3c.) Type of S.A.S. Description of Soil ' v Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been iss a by this oard of lelr------'' I Signed Date -/6 Application Approved by la ' Date 6 , Application Disapproved for the following reas ns ol Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( Upgraded( ) Abandoned-( )by k r c tr �kOf r C,^ at 4AJA G..-4 W, A rAe.Ziqhas been constructed in_accor ance with the provisions of Title 5 and the for Disposal System Construction Permit No'�Ltio3?-7 dated � Installer Designer / /7A e The issuance of this ermit-s no be o ued as a guarantee that the s r tem will function as'desi ne/. Date P g Inspector, y i ! , G gV/� P U r . V -- 1 No. 2P��" 377 --------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 33igpogar *pgtem Cottgtruction permit Permission is hereby granted to Construct( )Repair Upgra e( )Abgkndon( ) System located at M L j h�-�- tZ JvQ.*? > and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction rpust be completed within three years of the date of this e t Date: / Approved by 5/25/01 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM C ereby certify that the engineered plan signed by me dated �s--(� , concerning the property located at & C meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or.busiliess uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: 2 . A) Top of Ground Surface Elevation (using GIS information) B) G.W. Elevation + adjustment for high G.W. DIFFERENCE BETWEEN A-and B SIGNED : DATE: ��P)G NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:percexmp r 1 a ` I0.3X � C✓� �� o� ¢ nd � 1/ jv .3x "2Lx 'Z _ j3.SXZxL 5 �( -zx 2( x /a , 3 = 2L� 13 10 . Z -7.j Z wa 3 S ,s x -L X x x �� x �o.3 • a. ^� �x a ��.. c '.� _"' L<r^'Y �-• ,� -' +irrcr"w�';^s'•�,7 ,�zz �q l.�..- .n-�'� -,,,,r ti..,4. � - -_; . : _ "`Ot�' .i d c•. '•U'Er z-ems. # TOWN OF BARNSTABLE `J LOCATION �C�, SZ SEWAGE # O — 2-2 VILLAGEC;�� e ; ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ""Sr� N• -• : 1 SEPTIC TANK CAPACITY I C 7 U 6 LEACHING FACII:ITY: (type) (size / 1[5. 3 1Z .. o NO. OF BEDROOMS `` p7O X (6•.3 k o� BUILDER OR OWNER +'1�.5'F.;.� pp l f'.. PERMITDATE: 1�( t 5�: Q � COMPLIANCE DATE: Separation.Distance Between the: . ! i Maximum Adjusted Groundwater Table to the,Bottorr of Leach ng,Facility Feet Private Water Supply.Well and LeachingFacili ty ty_(If any,wells exist on site or within 200 feet of leaching facility):' Feet Edge of Wetland and Leaching Facility.(If any wetlands exist p within 300 feet of leaching"faciLty) VI✓1 t- Feet Furnished by " ------------ Q 9 �7k►n� .22 xpq � 4 °+e - - r -3nssi -aDNv ndv4o7 31.w o- :-a3C1sS1 1=1V�i2i3d--31'C1Q- - - ss 3aoav -� --�vrvr� s-a�o�in� T -- ,OO-T-- - � R �n �� � � � h � ? � 1i i y �.. � r „ �! No1s'f.jLX..... Fimic D.................. THE COMMONWEALTH OF MASSACHUSETTS LTH BOAR F / �----•-------------0 F..-... Q _:__. Apphration for Uhipoval Works Towitr than Urffttit Application is hereby made for a Permit to Construct (' or Repair ( ) an Individual Sewage Disposal System at, � - I N ation dress or of o/) /� ✓ham_..... ......_.. ._. .._�_.�__-'-_... ,1�`'x wne Address � Installer Address 127 Type o Building Size Lot.......... _...Sq. feet Dwelling—No. of Bedrooms........ ......................_......Expansion Attic ( ) Garbage Grinder ( ) Q, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other futures -------------------•------------ W Design Flow............5_L........................gallons per person pe day. Total daily flow..........___________..........gallons. C4 Septic Tank—Liquid capacity/0IM_gallons Length__________ Width_ ......... Diameter________________ Depth................ Disposal Trench—No_____________________ Width___ _d_ __.______ Total Length.................... Total leaching area..... ft. Seepage Pit No________________ i ter4e !lei _ _ . . otal 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........................ f� Test Pit No. 2................minutes per inch Depth'of Test Pit.................... Depth to ground water........................ ---t- O Description of Soil-------x j --�fi-.. t. '�lt'!f -•--------------------•---------------------------------------------•----•----•...-------- ( ----- __-------------------------_.__------------------------------------ W .1= �__ -----------7� -_ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued b the board of health. Signed------------=-- --e.._� -�.--- •'------------------------•-- ••------ /D----- ApplicationApproved BY------- -•-----------=......-..........................................................•..... .................................... Date Application Disapproved f o he following reasons:---•-------•--------------------••-•---•-•------- ............................... _......................... •-•-•................•-......_.._.....-------------------------•--...._.......-----•-•-••---•--------_....._-------------....••---•••------------...-••--._.---•-•-•--•-•----••-..---------•------..... _ Date Permit No....... o. Issued _ d - 7 f Date No...~ FRE .................. .................. THE COMMONWEALTH OF MASSACHUSETTS BOARDQF HEALTH — 2- 69 OF......)K,1; ............................................. ..................... ' 1 or DinpoiAlVorko Tonstrudion Prrmit Application is hereby made for a Permit to Construct (&-010"o"r Repair an Individual Sewage Disposal System at� ................. . ...Location• ......... ....... - . .................AA; "r ss ...............................................s or Lot No./; ............ .........K ...............7­ 17 Address .....A'J� _-----_------------- ............................................ .................................. Installer Address PQ Q Type of Building Size Lot..... h7.)t-0...Sq. feet U Dwelling'—No. of Bedrooms____.___7,?....................--------Expansion Attic Garbage Grinder ( ) aP4 Other—Type of Building ............................ No. of persons_._._._.-___________________ Showers Cafeteria ( ) P4Other �Zures ------------- ---------------------------------------------------------------------------------------------------------------------------------------- Design Flow_____ __. .......................gallons per person per day. Total daily flow..._._. . - ..........gallons. ------------------------ Septic Tank—Liquid capacity/_Vr.V' !t.gallons Length____�?...... Width..(^. ......... Diameter---------------- Depth---_----------- Disposal Trench—No..................... Width ---- Total Length____.____ Total leaching area____ . ft. De 1��letl otal leaching area--................sq. ft. Seepage Pit No. 40OVivive A..... -.0 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........................ G4 Test Pit No. 2................minutes per inch Depth of Test Pit_._.________________ Depth to ground water__________..__..____.._. P4 .......A................................................ ........................................................................................... 0 ............ "k Description of Soil.______. 44,_ -2, 41.�... ............................................................................................ U ....................................................................................................................................................v................................................... ---------------------------------------......................................I........................................................................................................................ U Nature of Repair's or Alterations—Answer when applicable.................................I.................. ................7............................ ................................................................................................................................................................................................... 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 bD en issued by the board of health. Signed . 1 , '«f... Z ..o4.............. . ate ApplicationApproved By... ...... ...... .......a.............................I.......................................... ........................................ 7) ` Date Application Disapproved folt7he following reasons:-----_---------------------_................................................................................ ........................................................................................................................................:.............................................................. Date Permit No. Issued........ ............................................... ............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... ......:..OF..:. er '14........................................ . 14 011ridifiratr of Tompliaurr THIS is TO CERTIFY,-That t1,Individual Sewage Disposal System constructed o Repaired by.................. ............. ........................... ......:............................................................................... I sta ler ;%at......................... v� .......... ;4411 7 ............. ------------------------------------------ 5 has been installed in accordance with the provisions of Attitle XI of 'fhe Staio'Sanitary Code as jj�esgwibed in the 0.1....' A9.Z............... dated---------!e 0000...........applicdtion for Disposal Works Construction Permit N' ......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....... ...... ........................ Inspector...--- ..................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Z .................. ................................................... No. .................... FEE... 0"Disposal Vorks TopiitrurfiAn pin t Permission is hereby granted. 4.��! ..... . ... .... . ........................ to Construct..(f;-�or Repair an Individual Sewage Disposal -System atNo..... ....... ...... . .... - ----_----_---_------ Str'eet'Z * No._ .. .... Dated..........Ir erm ............as shown on the application for Disposal Works Constructio,. . . . ...... .. .. ...... 1 ------------------------------- --------- DATE_...,(......... ...................................... Board of7ealth FORM 1255 HOBBS & WARREN, INC., PUBLISHERS t, '4 8/, 3e" 30" E- 4 C77 N ' C : RT •i F ( ED PLOT PLAN k. LOCATI O N f� S'C A L E: /" =.%O' D A T E �� �,�r/oG-✓�c/ off/ ,L�9�V� C.oU.e?" ,�L�9�./ �' 0 A T E y f ] I - lrP,, eaY CERTI RY THAT THE 6U. I LDING REG LAND SURVEYOR W N_ O N T H I S P L A N . 15 LOC ATED O N -TF1'E G. R0 U N0 AS 5 HOwN HEREON A ND I y' _ Oo C: O .N F O R M r O THE ( ii 0M N G BY - LAWS OF THE TO WN OF p f;'A��i�lSTi96G �_ W H E N C O N S T R U C T E D. LOW, 11t "� I• i r 3.AR NS TA. B L E SU R VE 'Y C UN S U LT A NTS, INC.. � ': ;✓err F-�'. , :' WEST YARM0lirH MASS , ae►i`..��r..ti ��; �� S