HomeMy WebLinkAbout0020 NAUTICAL ROAD - Health oe
°( 20-22 Nautical ,Road
Hyannis
A = 307 002
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplitation for Misposiar 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon V ❑Complete System ❑Individual Components
Location Address or Lot No. 0 a I a�,J �U,.` Q Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel g Q ..� wyrvr .t.5 02 j 56A �X—,A-k 6,Y
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building: -/ ^k O ei%j 06 65
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
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) 6 vOnV Q r Htdv-%J V
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 Certificate of
Compliance has been issued by this Board of lth. r
Signed Date / /A 6
Application Approved by Date 1 -�
Application Disapproved by Date
for the following reasons
Permit No. Date Issued zz
No-6" �. 7 Fee 4L,/ ;00000�
j THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVIIO SN - TOWN OF BARNSTABLE, MASSACHUSETTS
Nplication for Disposal 6pstrm Construction Permit
{
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(� ❑Complete System ❑Individual Components
Location Address or Lot No. a6 I a N C.JAm v (Z Owner's`Name,Address,and Tel.No.
Assessor's Map/Parcel 20 Wycv r%t 5 d 56A S A k 6
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( )
Other Type of Building No.of Persons Showers( ) Cafeteria
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd:;
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) C) d V raj O r v {c,JC! HVa v-v
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 Certificate of
Compliance has been issued by this Board of RMIth.
Signed Date
Application Approved by Date /
Application Disapproved by Date
for the following reasons
Permit No. (p " Date Issued 1111Z16
---------------------------------------------------------------------------------------------------------------------------------------
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 'f)COK M
�� a d �Vt.M 1S has been constructed in accordance q t
with the provisions of Title 5 and the for Disposal System Construction Permit N /(o �9 dated
Installer S(y A M 'V,,>\;�- Designer "
#bedrooms V v / ,�f Approved design flow �U fr T gpd
The issuance of this permit/shall not be construed as a guarantee that the system wi ,fW.n as designed.
Date ��/j( Inspector
---------------------------------------------------------------------------------------------------------------------------------------
No ~3 l--Y Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon
System located at () N r v-Fi c G _ R �/ r.n,(C
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction I
st be c'm �eted within three ears of the date of this permit.
Date ' 9 ��p� y Approved by
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
IIQCAIION A C. w{ 12 ti4IV 7/(A L le' SEWAGE#a 0d3``~°
VILLAGE H Y N 1u-f-s ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. d1
SEPTIC TANK CAPACITY /O
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS mhd (�h'T{�
BUILDER OR OWNER SAN7~d5 1 1 'So 7-002
PERMIT DATE: J 3 �o`I COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Fat
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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http-//issgl2/intranet/propdata/prebuilt.aspx?mappar=307002&seq=1 11/14/2016
.
Hazardous Materials Inventory Sheet Checklist
p G Date
Physical Street Address-Check database to ensure it exists
Working.Phone Number
Actual Amounts -( ie. gas being used to fuel machines, thinner to
clean brushes all count as hazardous materials-no blanks)
Storage Information - location of storage, how long is storage for?
If nuns, note that.
Disposal Information -where and who? If none, note that.
Applicant Signature -understand what is listed and noted
Staff Initial -any questions, know who to ask
Vehicle Washing/Rinsing? -give a vehicle washing policy and
plain it
Attach the Business Certificate with your sign off and comments
**The inventory form should explain what the business consists of and the procedures
thav are doing. Notes need to be left to explain what you discussed with then,
YOU WISH TO OPEN A BUSINESS?
.tr
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you .
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at.200 Main St., Hyannis.
Take the completed .form to the Town Clerk's Office; 1 st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get theBusiness Certificate that is
required by law.
N �g DATE: L Fill in please:
APPLICANT'S YOUR NAME/S: C�' 14 i
BUSINESS YOUR HOME ADDRESS: 7o 0 12c 1 016 O
�z .{ TELEPHONE # Home Telephone Number
-
vp
NAME OF CORPORATION -
NAME OF NEW BUSINESS' y l7 �' TYPE OF BUS INESS ��k I/
IS THIS A HOME OCCUPATIONzYES-- NO Y
ADDRESS OF BUSINESS` '' r' (� ✓1•, ��; MAP/PARCEL NUMBER [A sin ssesg� ) ,
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 pertainto.this type of business.
Authorized Signature** -
COMMENTS:
2. BOARD OF HEALTH
This individual has-been inforro7e)Mfh 'permit;requirem nts that pertain to this type of business:
�
iL Authorized,Sif ature 17; I S
MU Y" I1Tt o ALLCOMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has b n 'nformed the fcensing requirements that pertain to this type of business.
Ads horizedSignature
COMMENTS:
1� -
Date:
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: Zl ids CA PC A,Z Nd
BUSINESS LOCATION: Jo am,j'1,?AL l,5 01 INVENTORY
MAILING ADDRESS: vT`Z al TOTAL AMOUNT:
TELEPHONE NUMBER: o- B o _ o0
CONTACT PERSON: J
ln&'
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: �, L n o,
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze 9 Y gasoline or coolant stems) Miscellaneous Corrosive
(
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt&roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach) L
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Appl ci an s ature Staff's Initials _
TOWN OF BARNSTABLE
fLCr.ATION SEWAGE # �a05
VILLAGE ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. CX IU C C' �g
SEPTIC TANK CAPACITY 9 : E In- it L A�,z
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS Iv ��`'`�
BUILDER OR OWNER
PERMIT DATE: d COMPLIANCE DATE: 3`
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply.Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)' Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300'feet of leaching facility) Feet
Furnished by
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Tom-+
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D� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes Co'
j PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Migooal *poem Congtruction Vertu
Application for a Permit to Construct( )Repair( 1-�Upgrade( )Abandon( ) L1 Complete System P-ff6 vidual Components
Location Address or Lot No. L `� j A J/e 4- (p Owner's Name,Address and Tel.No. S
Assessor's Map/Parcel 3c) -oa 3KT A.,',4 L,1 rt-C d L X 31 '/'
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
CW/Z.-,C v
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 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 i ed b this Board of H th.
Signed '" to
Application Approved by ate
Application Disapproved for the following reasons
Permit No. �� Date Issued ——— ——
SOFee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2pplication for loigpooaf*p5tem Cott9truction Permit
Application for a Permit to Construct( )Repair( ..)-Upgrade( -)Abandon( ) ❑Complete System ®16 vidual Components
Location Address or Lot No. OAj.,4 UT c 4 L tp Owner's Name,Address and Tel.No.
Assessor's Map/Parcel. fi 'OlJ ZS A.1A U r/ Cd L f P /5 Y
r�, [/
Installer's Name,Address,and Tel.No. ,f'O S• ?9 f'/Z 08 Designer's Name,Address and Tel.No.
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 Type of S.A.S.
Description of Soil
i .
t
Nature of Repairs or Alterations(Answer when applicable). .f�/ti
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 issued boy this Board of
Signed � O ate
Application Approved by
Application Disapproved for the following reasons
i
Permit No. Date Issued . f
-----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
— THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( v)-Upgraded( )
Abandoned( )by A I(-Ad C ,4 A"'('® '3_S-o 57" Lti -- S-W e
at e;2 D j A /L,At.,7/c,4 L 4t S" habconstructed in accordance
with the pro °ons of Title 5 and the for Disp sal System Construction Permit No ated
Installer Designer
a
The issu ce of this ermit shall not be construed as a guarantee that the sys will functio designed.
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Date l f i l n z Inspector_ !? C
Q,.
--------------------------\---------- —
No. V '~ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Miopooar *pgtem Conotrurtion Permit
Permission is hereby granted to Construct( )Repair( -)-Upgrade( )Abandon( )
System located at .aP 0 /I!I(-
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:Constru Lion nXist be mpleted within three years of the date of this pe
Date: Approved by i
TOWN OF BARNSTABLE
LOCATION �j ... }/� // L '' SEWAGE #" ,/ `�`)
VILLAGE `l'^a U` v% t' ASSESSOR'S MAP & LOT
INSTALLER'S)NAME&PHONE NO. r, C/� ` C,
SEPTIC TANK CAPACITY
A
LEACHING FACILITY: (type) (size)
.{r,,�,
NO.OF BEDROOMS
BUILDER OR OWNER '�/'�' �
PERMITDATE: / �' r'' COMPLIANCE DATE: f :.
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet ofeleaching facility) Feet
Furnished by
Rf'AR
Li
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CON510.,\m-L4, m OF KasACHI nns
_ EXECL-MM OFFICE OF DN-MONAMN-TAL AFFAIRS
'DEPARTmENT OF ENVIItomaNTAL PROTECTION
OXE WL\TER STR_E--7.BOS:O\MA 0210E r6I',2.42-&UPtj
TRL'DT COLL-RECEIVED
1AN 1. 7 2001ARGEO PAUL CELLI:CCiD. t;;D g pWN OF BARNSTABLE Comtatss:one-
SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTIOMHEALTH DEPT,
PARTA
CERTIRCATION
PropereyAddress:22 Nautical Way; -Hyannis %wmet0-roe► .Tnhn CArnPnter
Address of 0-w:_l —
Date of Inspection: y�"�S—�
Nanre of Inspector.(Phase PeinUWM. 'E. Robinson Sr.
1 am a DEP appoved s airy inspector "Seedan 15.540 of Title 5 I310 CUR 15.000)
ur CopanyName: Wm. E . Robinson l�e tic Service
MalingAddress: PO Box 1089, Centervill MA
TekphOrw Number: �8 7 7 F,
CERTIFICATION STATEMENT
certify that 1 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 inspection. The inspection was performed based on my training and-experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
—1/pIsses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: /_U > Date:
The System Inspector shell submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty 130)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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer..if applicable.and the approving authority.
NOTES AND;COMMENTS .
Pyre 1 of 11
�: -••-+ea o-R!C\tRd Pane
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SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTWN FORM
PART A
CER I R CATIIOIY 1condrw"
Nope►ty Address: 22 Nautical Way, Hyannis
awner: Carpenter
Dane of Inspection:
INSPECTION SUMMARY: Cheek( 6 C o/ D:
A. :SY PASSES:
1 have not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. YSTEM 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.
Indicate y s,no. or not determined(Y.N,or NO). Describe basis of determination in all instances. N'not determined*.explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance lattached)indicating that the tank was installed within twenty 120)years prior to the date of the inspection: or
the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial infiltration or esfihration, or tank
failure is imminent. The system will pass inspection H the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if twith approval of the Board of
Health).
broken pipets)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health):
broken pipets)are replaced
obstruction is removed
Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Iconenued)
Propertyaddress:22 Nautical Way, Hyannis
owner: Carpenter
Data of Inspection:/�— Io- c)
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 it the system is tailing to protect the
public health. safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES M ACCORDANCE WITH 310 CUR 15.303 11)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water ,
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less then 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3, OTHER
S e Page 3 or 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM(INSPECTION FORM
PART A
CERTIFICATION leoeenuedl
ProoenyAddress: 22 Nautical Way, Hyannis
Df Carpenter
Daceate o of btspeetion:l
D. YSTFM FAILS:
You st indicate either 'Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the faiwre
Yes No
Backup of sewage into facility or system component due to an overloaded orelogged SAS or cesspool.
Discharge or pondmg of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
_ Required pumping more then 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LA GE SYSTEM FAILS:
You mus ndicate either "Yes' or "No' to each of the following:
T e following criteria apply to large systems in addition to the criteria above:
Th system serves a facility with a design flow of 10.000 god or greater(Large System) and the system is a significant threat to public
he Ith and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water 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)
The owner or perator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the D partment for further information.
• SUBSURFACE SEWAGE DISPOSAL SYSTEM•HSPECTION FORM
PART B
CHECKLIST
Property Address: 22 Nautical Way, Hyannis
Owner: Carpenter
Date oflnspeetion:
Check if the following have been done: You must indicate either 'Yes" or-No" as to each of the following:
Yes No
/ Pumping information was provided by the owner, occupant,or Board of Health.
None of the system components have been pumped for at least two weeks and,the eystem has been receiving"Mmal flow
rates during that period. Large volumes of water have not been in►t odueed into the system recently or as part of this
1 / inspection.
v _ As built plans have been obtained and examined. Note if they are not available with NlA.
_ The facility or dwelling was inspected for signs of sewage back-up.
V _ The system does not receive non sanitary or industrial waste flow.
_ _ The site was inspected for signs of breakout. ,
All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example. Plan at B.O.M.
_ Determined in the field(if any of the failure criteria related to Part C is at issue.approximation of distance is unacceptable)
I'15.302(3)lb))
_ The facility owner land occupants:if different from owner) were provided with information on the proper rrtaintanaoc ^f
SubSurface Disposal Systems.
s
f
Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
4ol ty Address: 22 Nautical Way, Hyannis
Omer: Carpenter
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ra 0 g.p.d.fbedroom.
Number of bedrooms dejign): Number of bedrooms factual):
Total DESIGN flow
Number of current residents:_
Garbage grinder lyes or no): A--0
Laundry(separate system) (yes or no):.&O If yes.separate inspection required
Laundry system inspected lyes or no)
Seasonal use (yes or no)._O
Water meter readings,if available llsst two year's usage Igpd): 1 g Q G-g n n n 142 , 500 gal.
Sump Pump (yes or no):it=d 1 998-1 999 204,000 gal.
Last date of occupancy�8' o-�+
COM ERCIALANDUSTRIAL:
Type f establishment:
Des flow: dpd ( Based on 15.203)
Basis f design flow
Greas trap present: lyes or no)_
Indust ial Waste Holding Tank present: (yes or no)_
Non- nitary waste discharged to the Title 5 system: (yes or no)
Wate meter readings,if available:
Last date of occupancy:
O ER:(Describe)
Las date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of 3 information:
"'✓ O-4 G
s7 z. R �
System pumped as part of inspection: (yes or nol-&Z o
If yes. volume pumped: gallons
R"ason for pumping
TYPE SYSTEM
Septic tank distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system Ives or no) (if yes, attach previous inspection records,if any)
VA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components. date installed W known)and source of information: _ I• ,� 2. A- Lw S ,d S,
Sewage odors detected when arriving at the site: (yes or no) 41 d
Page 6ofl.l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icaftnued)
'ropertyAdd►ess: 22 Nautical Way, Hyannis
Owner: Carpenter
Date of inspection:
BUBU G SEWER:
to on sne plenl
Dept below grade:_
Mater al of construction:_cast iron_40 PVC_ other(explain)
Diste ce from private water supply well or suction line
Dia . ter
Com ents: lcondition of joints. venting, evidence of ieakage,etc.)
SEPTIC TANK:_
Ilocete on site plan)
Depth below grader
Materiel of construction: Vconcrete_metal_Fiberglass _Polyethylene_othe►lexplain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
/ � z rr •
Dimensions
Sludge depth: Jti v
D
Distance from top of sludge to bottom of outlet tee or baffle:_!) 2
Scum thickness:7-1/ 1 7
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outle a or baffle: )6I
how dimensions were determined:lC
:omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage. etc.) ./e / y f y ��
A ++— L-3 1, t!11
GRE SE TRAP:
Ilocat on site plan)
Depth elow grade:_
Matena of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexpiain)
Dimensi ns:
Scum t 'ckness.
Distant from top of scum to top of outlet tee or baffle:
Distant from bottom of scum to bottom of outlet tee or baffle:
Date of ast pumping:
Comme ts:
irecom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert. structural integrity,
eviden a of leakage.etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTB4 INSPECTION FORM
PART C
SYSTEM INFORMATION leonotwd)
'romtyAddress: 22 Nautical Way, Hyannis
'owner: Carpenter
Date of Inspection: ! �L—/
TI DR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
Ito to on site plant
Dept below grade:_
Maier al of construction:_concrete_metal_Fiberglass_,Polyethylene_otherlexplain)
Dimon ons:
Capecit gallons
Design ow:_gallonslday
Alarm esent
Alarm I vel: Alarm in working order: Yes_ No_
Date c previous pumping.
Com nts:
Icon ion of inlet tee, condition of alarm and float switches.etc.)
DISTRIBUTION BOX:_V
(locate on site plan;
Depth of liquid level above outlet invert:_
Comments:
mote if level and distribution is equal. evidence of solids carryover, evidence of leakage into or out of box, etc.)
u-'
PU P CHAMBER:_
(loc to on site plan'
Pu os in working order: (Yes or No
Al ms in working order (Yes or No!
Co ments:
In a condition of pump chamber. condition of pumps and appurtenances. etc.)
` page 8 or n
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSpECTIDN FORM
PART C
SYSTEM NFORMATION Icenmasidl
*openYAddress: 22 Nautical Way, Hyannis
Owner: Carpenter
Date of kupwoon:
SOIL ABSORPTION SYSTEM ISASI.-Z'�'
(locate on site plan,if possible:excavation not required,location may be approximated by non-intrusive methods!
If not located,explain:
Type:
leaching pits. number: {
leaching chambers,number:
leaching galleries.number:_
leaching trenches. number. length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments
(note condition of soil. signs of hydraulicfailure, level of ponding. damp soil, condition of vegetation, etc.)
o.
V
t;
_CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depih•top of liquid to inlet rover U
Depth of solids layer:
)epth of scum layer: u
Dimensions of cesspool.
Materials of,construction,
Indication of grounowater. 4
infiovr (cesspool must be pumped as part of inspection)
Comme is
(note co ition of soil, signs of hydraulic failure. level of pondmg. condition of vegetation, etc.)
PRIVY:
hocaie on s to plan!
Materials of construction
Depth of s ids: Dimensions:
Comments
Inote con lion of soil, signs of hydraulic failure. level of ponding, condition of vegetation, etc.)
r pap(9 of I I
r ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Itanonuedl
Nop"Address: 22 Nautical Way, Hyannis
'weer: Carpenter
Date of inspec &F t,*,
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100- (Locate where public water supply comes into housel
f.
b
J
? Y
�L
O
s -
1
Pakc 10 of 11
1_
•. y
SUBSURFACE SEWAGE DLSPOSAI SYSTEM WSPECT"FORM
PART C
SYSTEM WFORMATM leanarnwdl
ropwityAddre": 22 Nautical Way, Hyannis
Ownw: Carpenter
Date of linspeebar 0—a/
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellir
Shallow wells
Estimated Depth to Groundwater;�-D Feet
Please indicate all the methods used to determine High Groundwater Elevation:
/Obtained from Design Plans on record
v Observed Site (Abutting property:observation hole. basement sump etc.)
/Determined from local conditions
V Checked with local Board of health r
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
Used USGS Date
Describe how you established the High Groundwater Elevation. (Must be completed)
el
. r
r
�':_Se: 9/2 7E Page 11or11
TOWN OF BARNSTABLE ,
, -)CATION =� �Il, v 1 I �" I—
VILLAGE_
VILLAGE NY ASSESSOR'S MAP & LOT - 1.
�ROSTALLER'S NAME&PHONE NO. 2 7r17 7
SEPTIC TANK CAPACI-Y
LEACHING FACILITY: (type) (size)
b
NO.0F BEDROOMS
BUILDER OR OWNER G '
PERMITDATE:,�. —;,2ci-6 COMPLIANCE DATE:
Separation Distance Between the:
4 Maximum Adjusted Groundwater Table and Botton4f Leaching Facility Feet
Private Water Supply Well and Leaching Facility/(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If'any wetlands exist
within 300 feet of leaching facility Feet
Furnished by
� �
3 ` 0 '
! �� �"
._?._ >.
f` t � .�.�
�.
` ,/
t ,r� � I
Y ��
o S\I �
P_ r
�. j/
1 i
1
S
� � '�`
No. i��" �' L) Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(pplicatton for MtoposaY *p$tem Conotructton VCrmtt
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
L c do ddress or of No. Owner's N me,Address and Tel.No.
ff_10 �L Naa ical Wa-\ Hyannis , MA John Carpenter
Assessor's Map/Parcel 30 7- o®Z--
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E . Robinson Septic Service
P 0 Box 1089, Centerville
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 Type of S.A.S.
Description of Soil Sand.
Nature of Repairs or Alterations(Answer when applicable) —
of a H 20 D-box and. 3 H 20 concrete leach chambers with
stnne all around..
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 issued by this aaVd of ealth. /g l
Signed ' e `�"� Date 2—
Application Approved by Date Z 4VO
Application Disapproved for the following reasons
Permit No. 710V_0—p Date Issued 2"C v d'Zodap
TOWN OF BARNSTABLE ,
LOCATION 2zQ to j TI C,- t- Lc> SEWAGE #Sao-J—65-
VILLAGE �5l i��n-�►-i,s ASSESSOR'S MAP & LOT 2 j
INSTALLER'S NAME&PHONE NO. J7V
SEPTIC TANK CAPAC1 Y 1.S&_o
LEACHING FACIL=: (type.) 3-h2L (size)Z12�
NO.OF BEDROOMS
r
BUILDER OR OWNER j0
1,1
PERMTTDATE:,,.4&,t ''a COMPLIANCE DATE:J
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply'Well and Leaching Faci,tO/af any wells exist
- on site or within 200 feet of leaching facility)
Feet
Edge of Wetland and Leaching Facility(Ifiny wetlands exist
within 300 feet of leaching facility Feet
Furnished by
/IT
i
i
f
rle• Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for Mizpoml *pg;tem Con.5truction Permit
Application for a Permit to Construct( )Repair(X )Upgrade( )Ab don( ) ❑Complete System ❑Individual Components
ocatio ddress or oY No. Owner's Name,Address and Tel.No. s
I0V� Nautical Way, Hyannis, MA John Carpenter ,
Assessor's Map/Parcel 30 —?! DOz_
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E . Robinson Septic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 4 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 Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable). Title-5 leach system, e ons i'S in
of a H 20 D-box and H 20 concrete leach chambers with t..
stone all around..
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 issued by this taaM o ealth. n 'M
Signed L. �`�"' Date ;7—
Application.Approved by Date Z•—/G—Z47/D
Application Disapproved for the following reasons
Permit No. Zoe-:=U Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
Carpenter BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that th Qn-site Sewage Di opal S stem Constructed(' )Repaired(X )Upgraded
Abandoned( )by Wm. E . Ro inson Septi�C Service
at;,.20-22 Nautical Way. Hyannis has been constructed in accordance
va the provisions of Title 5 and the for Disposal System Construction Permit No. ��' F(O dated ��—Zuv�
Installer Wm• E . Robinson Sr. Designer
The issuance of this permit shall not be construed as a guarantee that the Sys em will function as designed.
Date Inspector
C!
No.
716Z/V Q Yz Fee $5 0
THE COMMONWEALTH OF MASSACHUSETTS
Carpenter PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
1wie;pozaf *p.5tem Construction Permit
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 20-22 Nautical Way, Hyannis
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 must be completed within three years of the date of this it.
Date: z %� Approved by
38
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
y
j, W i l l iarn E.. Robinson;S,rhereby certify that the application for disposal works
construction permit signed by me dated 6-6`0 , concerning the
property located at 2 0-2 2 Nautical Way, Hyannis meets all of the
Mowing criteria:
• The failed system is connected to a residenti dwelling only. There,are no commercial or business
uses associated with the dwelling. /
The soil is classified as CLASS I an the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 10 feet of the proposed septic system
There arc no private wells wi 'n 150 feet of the proposed septic system
r There is no increase in flo and/or change in use proposed
• /hnJ
- . �uested or needed.
are no vari req
• m of the roposed Ieaching facility will not be located less than five feet above the .
adj d groundwater table elevation. f Adjust the groundwater table using the Frimptor
hen plicablel
• . will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
facility will not be located less than fourteen(14)feet above the maximum adjusted
ater table elevation,
omplete the following:
A) Top of Ground Surface Elevation(using GIS information) _
B) G.W. Elevation +the MAX:High G.W. Adjustment
DIFFERENCE BETWEEN A and B 2�
SIGNSD : e:::�J LJ DATE:
[Sketch proposed plan of system on back].
q:health folder:ern
W
�,