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HomeMy WebLinkAbout0006 MELBOURNE ROAD - Health 6-Melbourne Raab. ''ryanis`` A = I YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS NAME in town (which you must do by M.G.L.- it does gn'not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. AIR BiIx' Fill in please: Date: APPLICANT'S NAME: Uo,, rK YOUR HOME ADDRESS: 61 Gv�e I BUSINESS TELEPHONE # HOME TELELPHONE #: NAME OF CORPORATION: � NAME OF NEW BUSINESS _ } ocr' e '�, TYPE OF BUSINESS 'n,�V1 f"( �1G G�� � ��� ��� IS THIS A HOME OCCUPATION? � 1( S NO ADDRESS OF BUSINESS (o J Y:�,� ��I G'Z G f MAP/PARCEL NUMBERa` (Assessing) When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of Barnstable. This form is 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 town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** ,COMMENTS: 2. BOARD OF HEALTH This individual h s een info ed 1 the mit r i ments that pertain to this'type of business. 0 All WAIL-1 Authorized S' afure** 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: r TOXIC AND HAZ�A-RDO S MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: 5�0�� �12-� CONTACT PERSON: C�c.r��'­T i'N Q S EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: F jaov INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum © Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants . Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc, carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes 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 3 i i t 2 I j t I cc" E i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS � d DEPARTMENT OF ENVIRONMENTAL PROTECTION C � Sv� b� TITLE 5 OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6 Melbourne Road Hyannis MA 02601 Owner's Name: Karen&Andy Gauthier Owner's Address: Same Date of Inspection: August 22,2005 Job# 05-256 f n *-, rnc Name of Inspector: PATRICK M.O'CONNELL _ Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 ;~y Telephone Number: 508-428-1779 ca CERTIFICATION STATEMENT `— �� n 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 lift 1 approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: OF _X_ Passes ' Conditionally Passes IC cn Needs Further Evaluation by the Local Approving Authority = :y Fails w •0 L v, Date: 8/22/05Inspector's Signature: _ '*i•�� 5F� �oQ•��` 01111111 INSPEG 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. Notes and Comments: Observed 2-3Standing water in leaching chambers,tank is not in need of pumping at this time. ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Melbourne Road,Hyannis Owner: Karen&Andy Gauthier Date of Inspection: August 22,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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: 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. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titla S inanartinn Rnrm An ciinnn 2 1 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Melbourne Road,Hyannis Owner: Karen&Andy Gauthier Date of Inspection: August 22,2005 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Tola C incna^+;nn P—m 4rl,;i,)nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Melbourne Road,Hyannis Owner: Karen&Andy Gauthier Date of Inspection: August 22,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _X Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. —X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free 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.] No_(Yes/No)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• 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) 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. Titles Q 1nvnAPtlnn Rnr 411 v7nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property.Address: 6 Melbourne Road,Hyannis Owner: Karen&Andy Gauthier Date of Inspection: August 22,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X _ 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: Yes no X_ _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Titla C Tnonartinn Fnrm rli ci,)nnn 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Melbourne Road,Hyannis Owner: Karen& Andy Gauthier Date of Inspection: August 22,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): I Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 Number of current residents:3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):No Water meter readings, if available(last 2 years usage(gpd)): Two years total: 108,000 gal.=147 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd f Basis of design flow(seats/persons/sqft,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: None Source of information: Owner Was system pumped as part of the inspection(yes or no): 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 ob_tained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 4/2/01 Were sewage odors detected when arriving at the site(yes or no): No Titlo i incnortinn Fran rn;i,)nnn 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Melbourne Road,Hyannis Owner: Karen&Andy Gauthier Date of Inspection: August 22,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 16" Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: - Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" Material of construction:_X_concrete_metal_fiberglass polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5' long x 5.8' wide—1500 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle:30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 11" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear,liquid level at bottom of outlet invert. Recommend aumgina tank every three to five years. GREASE TRAP: No (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 integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): T41a G Incnnrtinn P^r 4/1 siinnn 7 r - Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Melbourne Road,Hyannis Owner: Karen&Andy Gauthier Date of Inspection: August 22,2005 TIGHT or HOLDING TANK: No (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 P tY Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" 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.): No solids or high stains. PUMP CHAMBER: No (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.): Titlo C i"enortinn Rnr Aii ci,)non 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Melbourne Road,Hyannis Owner: Karen&Andy Gauthier Date of Inspection: August 22,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: —XX_leaching chambers,number: One 500 gal drywell 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.): Observed 2-3tt standing water with no high stains. CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Titles S Tnenantinn Perm 4/1 ci,)nnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Melbourne Road,Hyannis Owner: Karen&Andy Gauthier Date of Inspection: August 22,2005 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. Melbourne Road Water service Driveway #6 29 32 18 19 28 38 Tit1a 1ncnPrtinn Fnr Oil;nnnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Melbourne Road,Hyannis Owner: Karen&Andy Gauthier Date of Inspection: August 22,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 15 feet 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 reviewed: 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) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 15 and topo map shows property above el.30. Title C lncn f;h n Rnr 4/1 C/')nnn 1 I _ TOWN OF B TABLE JLOCATION Rllboura SEWAGE #2 20 �D I'Ci,i,'IL.LAGE Q I ASSESSOR'S MAP & OT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY aao an �� _ /� LEACHING FACILITY: (type) / e) 500 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE:t2 .'COMPLIANCE DATE: �s � Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac 'n f cility) Feet Furnished by �� tl EN F J r 2 � r� lam__ NO. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH l7rA�9,J O F APPLICATION FOR DISPOSAL SYSTE CONSTRUCTION PERMIT Application for a Permit to Construct ()(Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components V�lel,2t�a�v� �t2' ot zoe2' jv�n.2''C� i"���tlV��� Vlhl �d I1c) ru' W f s i M /Parcel# / ��7��\�^fPyB�hess Lot# Telephone# staller's Name Designer's Name (off 3 - �s Address �p Telephone# Telephone# Type of Building: Lot Size v to 35 Sq.feet Dwelling—No.of Bedrooms Garbage Grinder qo(? Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. equired) '� gpd Calculated design flow C D gpd Design flow provided 23-4:7gpd 4-Plan: Date Number of sheets Revision Date Title `mil Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator A. d Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ag ees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 161;?—Ol FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 9 ..'¢ ;- }•1 V'n '--' '4.r ��1.+.y r.V+-,...�.'-^r7•( +"'�`n'.y.r..4"�-i1.�. ..^4f.. s,+ "•Y}efT+'IY ..� /y`.,rr� . ..� "if� � ,_ -.. r f .K1 No. TH%;,C:GIYJMONWEALTH OF MASSACHUSETTS FEE G^� �- - " " OARD OF HEALTH 6V1010-4 OF APPLICATION FOR DISPOSAL SYSTE �00- NSTRUCTION PERMIT Application for a Permit to Construct ()(Repair ( ) Upgrade ( ) Abandon p( ) - ❑Complete System ❑Individual Components 1 Z&�oczn Z� CPUI V 1 10 ! r .Ls'.wn�k M///Parcel# `-7 7���)) ess A//� / V, .9.R ,n Lot# Telephone#lop staller's Name Designer's Name r�sy Address , SI)�' /['�j� s Telephone# Telephone# d 1 r Type of Building: ' ' Lot Size t7 t7'65Sq.feet r w Dwelling ,Nos of Bedrooms ' Garbage Grinder (f Jty Other ' Type of Building No.of persons Showers ( ), Cafeteria ( ) ° Other fixtures Design Flow(min. equired) gpd Calculated design flow ( 0 gpd Design flow provided 9;�9gpd w• Plan: Date -Y44 1 flu Nut ber of sheets Revision Date Title t Description of Soil(s)_ l Soil Evaluator Form No. Name of Soil Evaluator . . CJVLVJ2 Date of Evaluation 1-Y �'✓/!/ `'' ,DESCRIPTION OF REPAIRS OR ALTERATIONS z { The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and-further aguees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date /(1 " / Iecti FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 q ------------------------------ No.S#-?) �—®rJ THE COMMONWEALTH OF MASSACHUSETTS FEE �G7Iif' � (2 GeXCK f-"H )-f'GL%d6 BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) Xcomplete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by, d /� ,,f�/ v at L G f 4100 to rt�r 6..L A6 lit.o 7ti has been installed in accordance with.the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.7411—0 8 dated Z 2 --a Approved Design Flow (gpd) Installer //�'n Designer: InspectolL•`` IC,&a, Lt t `Date The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. �" �a / THE COMMONWEALTH OF,MASSACHUSETTS FEE BOARD OF HEALTH .;; DISPOSAL SYSTE7plepair ONSTRUCTION PERMIT Permission is hereb granted to Construct ( ( Upgrade ( ) Abandon ( )"an individual sewage { disposal system at .. v �'� a,P (% Z as described in the application for Disposal System Construction Permit No. y b 'dated "2 ��Z�c, ( _ Provided: Construction shall be completed within three years of the&fe,of this per it.All local c di 'ons must be met. Z `./? t Date / ,�`� � a Board of Health' FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBSS WARREN TM PUBLISHERS- BOSTON x Sk 13547 Pg 1 5 #8700 02-08-2001 @ 02 : 01 P DEED RESTRICTION WHEREAS, Ellen T. Mirarchi and Thomas Mirarchi of 18 Concord Road, Shewsbury, MA 01545 is the owners of 6 Melbourne Road located in Hyannis, MA and being shown as Lot 40 on plan entitled"Subdivision Plan of Land, Barnstable, Massachusetts, Straightway, 14`h January 1971, Robert G. McGlone, Surveyor and Engineer, Main Street, West Barnstable, Massachusetts, for C.K.M. Associates",said plan filed with Barnstable County Registry of Deeds, Plan Book 250, Page 143. WHEREAS, Ellen T. Mirarchi and Thomas Mirarchi as the Owner of said lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a variance from the 310 CMR 15.214 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and to obtaining a building permit for this lot; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting the variance from 310 CMR 15.214, state Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this lot is requiring that the agreement for the restriction . of the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document. NOW,THEREFORE, Ellen T . Mirarchi and Thomas Mirarchi does hereby place the following restriction on his above referenced land in accordance with his agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. Lot 40, PIan Book 250, Page 143, house #6 Melbourne Road in Hyannis, MA, may have constructed upon the lot a house containing no more than one(1)bedroom. Ellen T. Mirarchi and Thomas Mirarchi agrees that this shall be permanent deed restriction affecting 6 Melbourne Road in Hyannis, MA, and being shown on the plan book 250, Page 143, Lot 40. For title of Ellen T. Mirarchi and Thomas Mirarchi, see the deed recorded at the Barnstable Registry of Deeds in Book 3443 Page 131. EXECUTED as a Sealed instrument this day of February, 2001 Ellen T. Mirarchi Thomas Mirarchi COMMONWEALTH OF MASSAC14USETTS ss. rc� Then personally appeared the above named Ellen T. M.irarchi and Thomas Mirarchi and acknowledged the foregoing instrument to be his free act and deed, before me, (,`OUNN BARNS T�SI6f.c t ry Publ -+- REGIS�HY DEEDS Tf COPY, ` pTRUE My Commission xpires: fc l 2q 2W2. j0V4N F.MEADC,RETSTER r BARNSTABLE REGISTRY OF DEEDS 'a i i i 1 I a � I � t IE �t p d-• NOn o l Xo' 0 kl17tlL•!k�..��...+ `� ffE-L Trr..iir I .I /y ..s..,.�:,«... - u i l 1 - I fr ..4............. �t i 6 } 0 o � i Z •...rt, :i-•%�` _.. f�O� R()KT 17I7 ItldMllr. 0 n — r,.•th rr.J.rA« (K'ATI()H: Gii / nd- r)a�• _ .,.ter.. L---- •. O •p•(cishne WNFgAc,l� �-^/ /���////`� ��.rxrr.� «..= +..T...I_- -l. f �•r.warwr W, �` GrIHp ///, ;;1�•r��1 - - i i i s OF B TABLE LOCATION t ibOTOVrNi SEWAGE #2O6 — 0b I VILLAGE Q ASSESSOR'S MAP & OT INSTALLER'S NAME&PHONE NO. f SEPTIC TANK CAPACITYOCAJf LEACHING FACILITY: (type) _ e) NO. OF BEDROOMS BUILDER OR OWNER 00 PERMITDATE:o? " �PC V f COMPL "CE DATE: � G*Y3� Separation Distance Between-the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet i - Private-Water Supply Well and Leaching Facility (If any wells exist on site or.within 200 feet of leaching facility) . Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac 'n f cility): , Feet _.. Fuinished by ./ 6' is 3 j TOWN OF BARNSTABLE .LOCA-flON � //�(���^� SEWAGE # X;5i0e-y.1t00n L4'II,LAGE ASSESSOR'S MAP & LOT ' 'S NAME&PHONE N0 1-n SEPTIC TANK CAPACITY LEACHING FACILITY: (type)- C.:PK,*%64 _ (size) Ad NO.OF BEDROOMS BUILDER OR4goR K�f�^ � ,� Z 0,0"V � PERMITDATE: —COWLIZOWE DATE: / /0S Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet i Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a t N ,w4 SYSTEM PROFILE e , 5 NEST HOLE LOGS TOP FNDN, AT EL, 33.0' (NOT To scALE> ACCESS COVER TO WITHIN 6 OF FIN. GRADE ;. ACCESS COVER (WATERTIGHT) TO AH OOALA, PE ENGINEERS /23.0' MINIMUM .75' OF COVER OVER PRECAST /` WITHIN 6' OF FIN, GRADE 2% SLOPE REQUIRED OVER SYSTEM 22.0' WITNESS: DONNA MIORANDI, IRScA cK , 2' DOUBLE WASHED PEASTONE DATE: / I \ yw 12 12 00 RUN PIPE LEVEL LOCUS FOR FIRST 2' : 3' MAX. PERC, RATE _ < 2 MIN/INCH g a PROPO SED 1 GALLON SEPTIC 20.25' 20.0' I�TEE \ CLASS i SOILS P# TANK (H- 10 > GAS 17-4� 19.17' �.0��� Cl C� C� O CD C� C7 C o0 `�- BAFFLE 18.50' CI C3 CJ 0 C] C7 CJ CJ 4` AT SIDES z 6 CRUSHED STONE ❑R MECHANICAL go 0 Q � 0 C7 � C� 3.5 AT ENDS w �23.0't 2' C7 CJ C7 C3 C7 CI = C7 a$ 16.50' COMPACTION. (15,221 C2D MIN o0 0 0 4 ELEV. Q , MIN < 14 r. SLOPE) ( r. SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE 0 �Q' 0 24.5 (_2_% SLOPE) DEPTH OF FLOW 4' TEE SIZES; 0 & A Q & A INLET DEPTH = 10„ 5„ LS 5„ LS LOCATION MAP (NOT TO SCALE) OUTLET DEPTH = 14 LEACHING E E FQUNDATION- 33' SEPTIC TANK 6' D' BOX 4 5 5' FS FACILITY ITS ASSESSORS MAP 268 PARCEL 238 12„ 10YR 5/2 12,E 10YR 5/2 ZONING DISTRICT: RB B B YARD SETBACKS: FRONT _ 20' LS LS SIDE 10' 36" 7.5YR 4/6 20.0` 3611 7.5YR 4/6 21.5' REAR - 1p' 11.0' PLAN REF: - 250/143 C C FLOOD ZONE: C PERC 0 MS PERC 0 M5 VCONTRACTOR TO VERIFY -ZONING SETBACKS PRIOR TO ANY 60" 10YR 6/6 60' 10YR 6/6 CONSTRUCTION 25.7 LAN IDLE BENCHMARK CTR OF CATCH BASIN CItIvA + .3 144 11.0' 120" 14.5' EL. 29.91 (ASSMD. QUAD) NOTES: NO WATER ENCOUNTERED Z 8 /� 22 NOT ALLOWED APPROXIMATED FROM QUAD TH2v SEPTIC DESIGN, (GARBAGE DISPOSER IS ) 1, DATUM IS 1 - G 1 0 ci- �r`�T� .� r , ILABLE 3 -----� D.ES I�:. E"�0.J --__D .._.:,. . ..-- � G 1 USE A 110 GPD DESIGN FLOW 3. MINIMUM PIPE` PITCH TO BE 1/8 PER FOOT: + 30 3 ' 10.1' SEPTIC TANK: 110 GPD C 2 ) = 220 4, DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASH❑ H-10 �^I 1500 5, PIPE JOINTS TO BE MADE WATERTIGHT, I 33 6.1 RES a, USE A -_-_ GALLON SEPTIC TANK 6, CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS, -o +S434.0 cp 140.1' Xt LEACHING: ENVIRONMENTAL CODE TITLE V. 167'---'{ 2(12.83 + 15.5) 2 (.74) 83.8 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT ' 0)�n' tT SLA8) � _ J SIDES: `' 147 TO BE USED FOR ANY OTHER PURPOSE. '; r► + 21.3 12.83 x 15.5 74 BOTTOM- -� _ 8, PIPE FOR SEPTIC SYSTEM TO SCH, 40--4" PVC, 3 ,sue PROP. DWELL. TOTAL: 312 S,F, 230 GPD 9. COMPONENTS NOT TO BE BACKFIL✓zED OR CONCEALED WITHOUT 4 ? 0.9 TF = 33 10.7 USE (1) 500 GAL. LEACHING CHAMBER (ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED 25 I FROM BOARD OF HEALTH. + 34. TH1 EQUAL) WITH 4' AT SIDES AND 3.5' AT ENDS + 23. - - + 24.8 1 2.5' N + LEGEND TITLE � SITE PLAN o � _ CJ 3 ,a 8 8, 0 100.0 PROPOSED SPOT ELEVATION OF 30. L T 40co LOT 40 MELBOURNE ROAD O 100x0 EXISTING SPOT ELEVATION T. N+ 20,8 4 10,0 5 SO. IN THE TOWN OF: 0.2 ACRE 110.08 100 N a PROPOSED CONTOUR ( WEST H YA N N I S P O R.T) B A R ICJ S TA B LE N 100 EXISTING CONTOUR PREPARED FOR: MARKWOOD CORP. O m ao 24.0 j W+ 4.3 N N N 2 .4 32.9P '� "� "� N 40 60 32? 20 0 20 BOARD OF HEALTH MA SCALE: 1'' = 20' DATE: DECEMBER 28, 2000 APPR,BVED DATE off 508-362-4541 fax 508 362-9880 OF MAS down cape engineering, inc, 10 1 ARNt ALA J � ARNE H: G� w. ZE H, 0 CIVIL can -� CIVIL ENGINEERS U oJa> so7sz �- LAND SURVEYORS 9 Nc:. 2fi`4t3 �o� ;;, � 939 vain st: yarmouth, rya 02675 H. OJALA, P.L.S. J4DATE 00-337