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0155 OLD YARMOUTH ROAD - Health
',155 OL'D,YARMOUTH-ROAD;;HYANNIS A=' 344 077 3� �Je I� I I YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates [cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town [which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: .hi b6 /� Fill in lease: ROAM`�; - 3i , li rN �i l APPLICANT'S YOUR NAME/S: ReAn 5• h0.•u V,� - I-I- 'J's . " 1 u 1 ^R`�1,1'J'r�lr^`� � '`�" �''�' JR x BUSINESS YOUR HOME ADDRESS: J S5 Old Xc r•rno,+h_ a:n :s M A OZ6 0 .� �•r.._rrlrri�t"/1Fff P "�,I 5d8 /71..�Z�j 7 t:i,;1Sa: � IPI!111 Dg 00 - r4 • .S.{rJ.��,rd�^�' HONE # HomeTele hone Number S �l L(CoGS p �V,'rJ. J7rar;rS'lliu!d;ieli'.�u'7l�?.i r,,.r;� rr NAME OF CORPORATION: I[ nd v' 55 oPb�/w ' 7 5 �y NAME OF NEW BUSINESS A Il aoe ctirin 'E, TYPE OF BUSINESS r;m. br,'cci I'd it IS THIS A HOME OCCUPATION? YES NO ✓ ADDRESS OF BUSINESS )55 —(3-TJ— Yarmo,f-k MAP/PARCEL NUMBER �_( G [Assessing] 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 CO Is. 10 R'S OFF CE This individ e n ' o el a y r it re uirerrients that pertain to this t�iPe ofi business. ut orized Si * C COMMENTS: AA 2. BOARD OF HEALTH This individual ha for e f permi requirem is that pertain to this type of business. Authorized S&hature** COMMENTS: � M 1Ik1'tl"ALJ ITAIAKIJUMS SACSREG"T110ft 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: 6/7-1 /V0I6" TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS�?-1 -A II GLp9, RCkr.-(1Q, BUSINESS LOCATION: /5 5 01d YA.rm.ov* 1Q_aJ dnaA f Zyd INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: 560 771 —Z 07 CONTACT PERSON: _120 1avL 6CLU v;n EMERGENCY CONTACT TELEPHONE NUMBER: 600 L/00 utf) MSDS ON SITE? TYPE OF BUSINESS: ar,►Xe Fa6r"CCJ,'0n INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics.and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please (please list): Metal polishes Co114 I� rl Laundry soil &stain removers (including bleach) ��a C®� LP4 QV Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash ( Z J/---Ir d WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Appl an s Signatur Staff's Initial 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 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" FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and get the BusinessCerjificate that is required, by law. iF , , Fill in please: Date: I ) ON r APPLICANT'S NAME: © rV 6 YOUR HOME ADDRESS: 6 l! ov `�-} IS`(1 ' of. mnS i tp'i x r{v{ d qo BUSINESS TELEPHONE # HOME TELELPHONE #: q< 6`t NAME OF CORPORATION: FID # - _Z(60 4`6 S NAME OF NEW BUSINESS' L CPPe= -2T ft L.S TYPE OF BUSINESS rZ IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS ) ® L11 \JL Vy ou`TK - MAP/PARCEL NUMBER344 " (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 _ t This individual has bee informed of anyrmit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has b n i formed of the permit requirements that pertain to this type of business. .~ _, ... G�r MUST COMPLY WITH ALL Authorized Signature** MAZARDOUS MATERIALS�REGULATIONS COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) k This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: �+ Date:S/2-1 / 11 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: L _E_ L-> BUSINESS LOCATION: VENTORY MAILING ADDRESS: TOTAL AMOUNT- TELEPHONE NUMBER: j6 n i t CONTACT PERSON: V_IG kKr\z EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials AL�aPe a ers 155 OLD YARMOUTH RD. HYANNIS,MA 02601 _ 771-2117 FAX 771-2165 AV Irl C"/om a6ricafor�s7 ROBERT FENNER OWNER 6 zz) TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Statio s,Repair satisfactory BOARD OF HEALTH 'y 2.Printers3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANY (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MAT IALS Case lots Drum-, ,. , Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline Jet Fuel (A) jp�n7��Zarnenrin B) "Heavy Oils: waste motor oil (C) IV ° new motor oil (C) Ae j transmission/hydraulicr-7 Synthetic Organics: + =- degreasers Miscellan�� IV f DISPOSALIRECLAMATION REMARKS: 1. Sanitary Sewage 2.W ter Supply O own Sewer Public n-site OPrivate t- 3. Indoor Floor Drains YES NO f'" u � 0 Holding tank:MDC_ 0 Catch basin/Dry well _ 0 On-site system ` J 4. Outdoor Surface drains:YESNO O ° 0 Holding tank:MDC Catch basin/Dry well h� 0 On-site system 5.Waste Transporter Name of Haulcr Destination Waste od 2. . ° Per n W Interviewed Inspector Date 155 OLD YARM OUTH 140. kHYANNIS, �- MA 02601 771-2117 FAX 771-2165 i Cusloin 7,srict7/ors Y ROBERT FENNER _ OWNER TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM p Mail To: NAME OF BUSINESS: a0 C�'n e ���c�Pr `� _ Board of Health MAILING ADDRESS: 1�5 ma. A , vA Nt S Town of Barnstable E TELEPHONE NUMBER: P.O. Box 534 Hyannis, MA 02601 CONTACT PERSON: - B c-`t ne_<c— Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous characteristics and must be registeredwla Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners !/ Hydraulic fluid (including brake fluid) / Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, +� Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt& roofing tar Leather dyes !/ Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) I/ Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) 1 (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers �-- Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine, Gas Stations,Repair O satisfactory 2.Printers BOARD OF HEALTH 2.Auto Body Shops ,' ? O unsatisfactory- 4.Manufacturers COMPANY 6 ,W (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS PASS: 7.Miscellaneous 1� QUANTITIES AND STORAGE (IN= indoors;OUT=outdoors) MAJOR MA S Case lots Drums Above Tanks Underground IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) transmissio�ydraulic Synthetic Organics: degreasers Miscellaneous: 0 CV W AAI o a o lop e� DISPOSAL/RECLAMATION REMAS: 1. Sanitary Sewage !; a ater Supply ILS &C Town Sewer XPublic On-site 61rivate j 3. Indoor Floor Drains YES NO / O Holding tank:MDC O Catch basin/Dry well .01 O On-site system 4. Outdoor Surface drains:YES NO O Holding tank:MDC \� Catch basin/Dry well ®® O. n-site system 5.Waste Transporter DestinationName of Hauler N(a L I YES INO 1. 2. co a e Person (s) Interviewed Inspector a a ers p 155 OLD YARMOUTH RD. HYANNIS,MA 02601 771-2117 FAX 771-2165 it+ C sfom 7abricalors OWNER SUSAN FENNER TOWN OF BARNSTABLE OMPL/ANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2. Printers BOARD OF HEALTH 3.Auto Body Shops " unsatisfactory- 4. Manufacturers COMPANY A l I ��� t�ld�� O (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS Cik Vk"& 1 Class: 7. Miscellaneous C r)nt S QUANTITIES AND STORAGE (IN= indoors; OUT=outdoors) MAJOR MATERIALS Case lots L)rums Above Tanks Underground Tanks '_1 IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) X �" Y �•0 v new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: :r6 IC 5--rCA,1K DISPOSALIRECLAMATION REMARKS: 1. Sanitary Sewage 2. Water Supply P01 ° ) : I rV ),r AF�own Sewer `.Public ' W" ip On-site OPrivate A oat. 6 1, 3. Indoor Floor Drains YES NO� O Holding tank:MDC I t- c,_nLS jkaUikPT. LC� O Catch basin/Dry well O On-site system y 4. Outdoor Surface drains:YES NO�L ORDERS: O Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product Licensed? YES N0 1. 2. Per n(s) Interviewed Inspector Date dweapewemer 155 OLD YARMOUTH RD. HYANNIS,MA 02601 - - 771-2117 FAX 771-2165 � v CUSfom.Ta&Ca10 S ' ROBERT FENNER OWNER- TOWN OF BARNSTABLE C MPLlANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops ff�,// 0 unsatisfactory- 4.Manufacturers COMPANY XI,4 9 !�'J�.� (see"Orders") 5.Retail Stores 6.Fuel Suppliers 1 ADDRESS 6Y, 4 S mil"' BYL� 35; '� 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATE S Case lots Drums Above Tanks Underground IN OUT IN OUT IN OUT #&gallons Age Test Fuels: 01 Gasoline,Jet Fuel (A`)�" IA,4 :�i Heavy Oils: waste motor oil (C) V0 " ne �r oi'Irt6}- tr rau is Synthetic Organics: "e easers Miscellaneous: j -7 DIS OSAL/RECI AMATION REMARKS: 1. Sanitary Sewage 2.Water Supplyr O Town Sewer Public #On-site OPrivate 3. Indoor Floor Drains YES Noy O Holding tank:MDC 0"'��6 O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO ORDE : folding tank:MDC - R C5i7zez_ atch basin/Dry well.tn-site system 5.Waste Transporter Name of Hauler Destination Waste Product 2. e son ( ) nterviewe nspector Date Commonwealth of Massachusetts Still Executive Office of Environmental Affairs Department of Environmental Pr otection r : RECENED Wi111am F.weld _MAR .7 1995 k Governor HEALTH DEPT Trudy Coxe secret. eoer, MW IN WNSTAUE David S.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' 155 Old Yarmouth Rd PART A CERTIFICATION Hyannis Robert Fenner Property Address: - y " Address of Owner: .Date of Inspection: 02 'C1 (If different) ; Name,of Inspector: W.E. Robinson Sr. Company Name, Address and Telephone Number: W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT `77--77 I certify that I'have personally inspected the sewage dispos�l sgsferti t 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: .Zpasses Conditionally Passes _ Needs Further Evaluation By the.Local Approving Authority' _ Fails Inspector's Signature: li(�/G �'�-� 5C1 —' Date: The System Inspector shall submit a copy of this inspection report to the'Approving Authority within thirty (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 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. INSPECTION SUMMARY: Check ;B, Q or D: A) SYST M PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate es, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If"not determined", explain wiry not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or,tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revis d 8/15795) 1 • One Winter.Street " • Boston,Massachusetts 0�106 • FAX(617)55&1049 • Telephone(617)M-5500 i,Printed on Recyded Paper y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 155 Old Yarmouth Rd Hyannis Owner: Robert Fenner Date of Inspection: 3 _9_0.erg L B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) 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 pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTH R EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: C nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the pu lic health, safety and the environment. 1) S STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT HE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE 'VIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system ha< a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 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 i ppm• D] SYSTE FAILS: I ha a determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for t is determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the ilure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8 15/95) Z I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 155 Old Yarmouth Rd Hyannis Owner: Robert Fenner Date of Inspection: 3 _�0-� Z. , D)SYS FAILS(continued): 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 1/2 day flow. 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 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 I 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. El LARGE S STEM FAILS: T e following criteria apply to large systems in addition to the criteria above: T e design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety nd the environment because one or more of the following conditions exist: 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 r operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirement of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. _ 3 (revised 8/15/05) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 155 Old Yarmouth Rd Hyannis Owner: Robert Fenner Date of Inspection: Check if the following have been done: y/Pumping information was requested of the owner, occupant, and Board of Health. _V None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _kAs built plans have been obtained and examined. Note if they are not available with N/A. he facility or dwelling was inspected for signs of sewage back-up. _I/he system does not receive non-sanitary or industrial waste flow 1-4/he site was inspected for signs of breakout. _All system components, excluding the Soil Absorption System, have been located on the site. he 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. ,JThe size and location of the Soil Absorption System on the site has been determined based on existing information or a/h'e roximated by non-intrusive methods. facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 155 Old Yarmouth Rd Hyannis Property Address: Robert Fenner Owner: Date of Inspection: 3 a�_n `77 FLOW CONDITIONS RESIDENTIAL: Design flow: 5�1/0 allons Number of bedrooms: 2-- Number of current residents:V A y O^1 Y S7 l d i' `� Garbage grinder(yes or no):-&—o Laundry connected to system (yes or no):—)L'.' S Seasonal use (yes or no):�v Water meter readings, if available: Last date of occupancy:3—�O—g G COMMERCIAUINDUSTRIAL: Type of establishment: C.tl �� C4 o Design flow:`-�� d allons/day 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)A. O Water meter readings, if available: Last date of occupancy:= a— OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of in ormation: 7A., c /may•�� 15 �l System pumped as part of inspection: (yes or no) &-O If yes, volume pumped. gallons 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) /(i 0 (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Old Yarmouth Rd Hyannis Owner: Robert Fenner Date of Inspection: 3 oafJ-C} li SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: t concrete _metal FRP other(explain) s G ® /_ // 2- o �rz A d` Dimensions: Lz C. -' // -r d'?' d vie . Sludge depth:of slud Distance from top ge to bottom of outlet tee or baffle: J S' Scum thickness: 3 ' i Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: / 3 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,)epth of liquid level in relation to outlet invert, structural integrity, evidence of ka e, etc.) n�S a c1 2 GREA TRAP:_ (locate n site plan) Depth elow grade: Materi I of construction: _concrete _metal _FRP —other(explain) Dimenst ns: Scum thi kness: Distance rom top of scum to top of outlet tee or baffle: Distance from bottom of crurr, t� hOttom Ot 011tiet tee or baffie: Comme ts: (recom endation 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. (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 155 Old Yarmouth Rd Hyannis Property Address: Robert Fenner Owner: Date of Inspection: 3 p`� TI T on OR HOLDING TANK:_ (locate site plan) Depth low grade: Material of construction: _concrete _metal _FRP—other(explain) Dime ions: Capa it : Rallons De n flow: gallons/day Alarm evel: Comm ts: (conditi n 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: (note if level and distributiun is equal, evidence of solids carrlo•,cr, evidence of leakage into or out of box, etc.) PUMP C AMBER:_ (locate on site plan) Pumps i working order.(yes or no) Com nts: (note co dition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Old Yarmouth Rd Hyannis Owner: Robert Fenner Date of Inspection: 3—2 0—9 6 / SOIL ABSORPTION SYSTEM (SAS): 1/ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 0 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) D t C T Ga G2 S C) 2A�G CESSP OLS: _ (locate n site plan) Number nd configuration: Depth-to of liquid to inlet invert: Depth of solids layer: Depth o scum layer: Dimen ons of cesspool: Mater Is of construction: Indi ion of groundwater: inflow (cesspool must be pumped as part of inspection) Comme ts: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI (locate o site plan) Materials f construction: Dimensions: Depth of olids: Commen s: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 i- • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Old Yarmouth_ Rd Hyannis Owner: Robert Fenner Date of Inspection: o-,01 4, SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' old Y Rd i ( I ) t tj -- i DEPTH TO GROUNDWATER i Depth to groundwater: d;�- feet method of determination or approximation: 13 0 j� h6 & (revised 8/15/95) 9 ASSESSOR'S MAP NO. -PARCEL 61 LOCATION SEAG PERMIT NO. VILLAGE INS LER'S NA E B D°R.E'S $__ B U I L D E R OR OWNER /4t/e/x/ C6k. - L04 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Cp - � tte \ i t � � � �, 1 FRs.....a..0............... THE COMMONWEALTH OF MASSACHUSETTS BOARD F 1- EA T f .. Appliratiou for Ui4pnoal darks Tamitrurtinn 11amit Application is hereby made for a Permit to Construct ( ) or Repair ( Z--Y"an Individual Sewage Disposal Systemat: Location-A/dress of Lot No. -- - -. -. ------ q Chw e Address ------ ------- ------------------------ ... . •-------- ..... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) G4 Other fixtures ...._......•..............•••--. • ... w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date............................---------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..._........_......_.__. Test Pit No. 2........_.......minutes per inch Depth of Test Pit.................... Depth to ground water........................ t..... �f'�0 Description of Soil......... --•-- --------------•----•--------. -•------- ----......----•--•----•.---.......--------•------- x ----------------------------------------------------------------------------------------------•-------------------------...... 6 ----- ------------------ ----- 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 iITL% 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bean issued by e b rd of ealth. n/ S n d- ° r 1�P �+ . �n Da Application Approved BY `' -----•__•.. Date Application Disapproved for the following reasons-------------•--------------•-•------•-------------------------•-------------------------•--••-••......--.------ - -•---•-----•---•••-•----•----••-••-...•--.....----•-•-•---•---••---•------------•.............................................•-•--------•---------••-•----••-------••--•••---•--••--••-----------•----- . l Permit No Date........... .... . . ....... Issued. --t Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA TH t� �, � .fF✓,pro} �;!'-.����+ ........... f .. OF... .zi 1... 'c' `s. .............................. Appliration for Disposal Works Tonsdrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (4.•'T} L Individual Sewage Disposal System at ............................� �4..........r� 3'� c.2 e j F°'" ,,..........•--• Location.Address or Lot No. n r g x""' Address .� F9 .._..... '..p'E'. ��:.��._...�.`... / •.l._,.3uVY !*_S�r�d e�..Si...._. v....... .............................................................................................. Installer Address Type of Buildings Size Lot............................Sq. feet Dwelling if No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building ........ No. of persons............................ Shower's — Cafeteria aOther fixtures -----•--•----•---•------------------•----•------•--------.----- Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic,Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter............ ..._..._ Depth below inlet.................... Total leaching area.................sq. ft. tan Z Other Distribution box ( ) Dosingk ( ) Percolation Test Results Performed by.................•------....-•••••••••••----•--•-••-•....._......•--.-_... Date............................ 14 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................" I Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ^�:....... -------------------------------- ----------........................................... ------------------.----.----- 0 Description of Soil........: =r t ............V lf't, ......................•----•----•------•---•-----.....----.....----•--•----------................. V ------------- --.......... ---•---__-__.....:_..... -------•-----........ .-_-_.••••---._....... W •••-------•---'.............•------•-----------------"•--•--'-----------•--•..........•-•••-----....'•--•...__••---'--..__e..___ J .._..... U Nature of Repairs or Alterations—Answer when applicable......r___.."."K............>_ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIS' 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issued by/the bdard�,q f.health. igned {: ?a£' c... . '.....:........... Dt Application Approved B _ ��...i . • .....•-•..........s--... ... y Date Application Disapproved for the following reasons:............................................................................................................ ----------------------•-•-----•-•----............---.....---...............--•--............---•----•-••.-•••••-•••-......................•-•----•..............••-•-...................---•......._..» Date Permit No.r_7'' '- - .. . -»..» Issued_............................................«......._ Date THE COMMONWEALTH OF MASSACHUSETTS d �t BOARD OFF HEALTHY , ................. ....... ..w...._..t ..... ............................. (Irrtif iratr of Toutphaurr TKIS/LS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by.. ......... ...«5d^ G_� v..........an all.. ............. ._..... ..... ................... «.._ r Install at.... ` ' �" / 9`l"�i ..._.. '.. ?.!...................................................•----_---- ........ ..... has been installed in accordance with the provisions of TITLE 5 of The tate Sanitary Code s de r rein the application for Disposal Works Construction Permit No._`_..� '_.......__ .. .._..... dated.. .,..� ".:: ......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUED AS A GU RANTE THAT THE SYSTEM WILL FUN TION,„.SATISFACTORY. DATE.... «j.� ........................ . ....... Inspector .. d ............................................................ THE COMMONWEALTH OF MASSACHUSETTS .� BOARD OF HEALTH FEE........................ r Tono#rnrtiun V,,vrmft12 Permission is hereby granted . . . ...... . ......... .......»»»....... ....... to Construed,( Q) or Repair O a Individual F Sewage D7104 Syt atNo.-I. .................................... Street , ^ as shown on the application for Disposal Works Construction erinit NC;.. ... '.W_-A, Dated..-_ .� `? ........ ... �...... ` ---- Board of Health DATE....... FORM 1255 A. M. SULKIN, INC., BOSTON -