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Home My WebLink About0024 QUAKER ROAD - Health 24 Quaker Road Hyannis P A = 310 291 4 �l P 9 1 �Ir o I n 4 F a O 6 f j.. o TOWN OF BARNSTABLE BOARD OF HEALTH i ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 1 Time: In Out Owner L to IZ Cl 1.,tjo Tenant 14,410 Address LIQ 001 �'�� Address O-1 QUA KKR R> Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply �l® _ 5. Hot Water Facilities G— TUNIC- ®r 5 g (orJ 6. Heating Facilities 7. Lighting and Electrical Facilities 8.Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 2p-- O(o y 17. Temporary Housing KA 18. Driveway Width 19. Number of Tenants Observed �� PART II NO St-I✓ep,N 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms 3 Number of Vehicle ax) Number of Persons Allowed (max) Person(s) Interviewed /1v�Iv \ Inspect If Public Building such as Store or Hotel/Motel specify here Date:jd2 1 Qr0 I/ TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION Q�i ,g �Q ! INVENTORY MAILING ADDRESS: ? A &4 rid . TOTAL AMOUNT: TELEPHONE NUMBER: 501 '1 3&— 1'7 CONTACT PERSON: 9,'ZA4A 2 Fla It i 4 4 EMERGENCY CONTACT TELEPHONE NUMBER: SDL 3�t- 1/11 j® 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 n 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 Initial TOWN OF BARNSTABLE BAR-W Ordinance or Regulation WARNING NOTICE ' y4 Name of Offunder/Manager Address of. -Offender MV/MB Reg.# Village/State/Zip Business Name "" /r,''&�/�i/pm, on ' / 20 1 Business Address Signature of Enforcing Officer Village/State/Zip4t , '4 .3 Location of Offense Enforcing Dept/Division 7U Offense ,,,,.. ) Facts A e. &" ' j N V_ z ;'.. This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education, efforts and warning notices are attempts to gain voluntary compliance. tSubsequent violations will result in appropriate legal action by the Town. WHITE OFFENDER CANARY ORD./REG.-PROG. FINK-ENFORCING OFFICER-"``GOLD ENFORCING DEPT. TOWN OF BARNSTABLE BOARD OF HEALTH J i ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date i z Time: In 10;00 Out /0-7 'C Owner. v ZZ (fV E. L, N d Tenant ��y i-��2 Ltd' 94 Address L 6)4 L,-- L YZO Address A P-14 a 2(e Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities f 3 0 C) TF-0 6. Heating Facilities pec-r 10 7. Lighting and Electrical Facilities w �� 8. VentilationV (Z' it 9. Installation and Maintenance of Facilities 10. Curtailment of Service le¢ p"v 11. Space and Use 2 3 6Ir2. v ,.► �aS�w .a 12. Exits 13. Installation and Maintenance of Structural o, D U�-J O \'�.�! Z�91 Elements LCA C. O t4 n; ..c 14. Insects and Rodents F,Mf4f tic�eti %� 15. Garbage and Rubbish Storage and Disposal ��v`c VA 16. Sewage Disposal 1 V A-� 17. Temporary Housing o � 18. Driveway Width L.0 V \11 eA G;-d 0vv/c. 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition —rU 1 -PG STAFid Number of Bedrooms S i Number of Vehicles Allowed (max) Number of Persons Allowed (m ) Person(s) Interviewed i inspector t ` If Public Building such as Store or Hotel/Motel specify here -r r.,.,..- ----:,,..r >-•:_,r-.,- ,,. .._:r-::-T-;,,, ---•^_,--, ..e,:.-: r .:,.,� ::...,.. �T,,,,-.. nw„r;r�a-dam ---�'••`.. �.,,,--.`.. --.-.^Z.:•:r--�._w-.,. .. "7'•s-• -'.T'"ra^--^.-` .r'r�.-J�.,,..,..�-�..,-.'+'�.,•"!vim-. � -^—^._- ... t. TOWN OF BARNSTABLE BAR—W ' Ordinance or Regulation WARNING NOTICE Name of Offender/Manager Address of Offender Z1,1 611-1k, t-I iLLC aO . MV/MB Reg.# Village/State/Zip tA i L), 1,1 Business Name �/ �trl �/pm, on �'�-rF/ 20 0 Business Address Signature of Enforcing Officer a Village/State/Zip *k r Location of Offense l,.i<'s+ ` e..a- -:, Enforcing Dept/Division Offense. Awr 04. 1= + .► as C �� 3r w�.,�.eE. •, C6114 1ft1%, Facts V40"6(.. Co A.,' P.- too"I A� This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Edu cation. efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORDJREG.-P,ROG. RINK-ENFORCING OFFICER-'�GOLD-ENFORCING DEPT. p � LllLn Q- .. OFFICIAL " U-SLE C Postage $ �i Certified Fee r U PSsstirark p Return Receipt Fee l (Endorsement Required) Restricted Delivery Fee (� 0 (Endorsement Required) oOj LO Q r� Total Postage&Fees W fu Sent To �. M:._.....a.- -- ------------------------------ Street,Apt.No. or PO Box No. G 'p y� r\- ----------------- / 1`.�.. //�1J� Ci State,ZIP lS IJC/ M If. I Certified Mail Provides: i ® A mailing receipt o A unique identifier for your mailpiece e A record of delivery kept by the Postal Service for two years Important Reminders: ® Certified Mail may ONLY be combined with First-Class Mail®or Priority Mall®. o Certified Mail is not available for any class of International mail. . a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. • For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". is If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail.- IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530.02-000-9047- i COMPLETE ■-�Cornplete items 1,2,and 3.Also complete A. Signature Item 4 if Restricted Delivery Is desired. ,n Q I( ❑Agent X ■ Print your name and address on the reverse I— 0( 1 Z G n ❑Addressee { so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery I` ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from Rem 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No I— A 3. Service Type Q d Z ' (Certifled Mall ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number i i •t a l c "!; l y7O06" 27,5�+`0002 11041 i7E99ftis (Transfer from service label) PS Form 3811;February 2004 Domestic Return Receipt 1025957M-1540' UNITED STATES POSTALV11~ " ""`j` % t r,.. �" w��`�s n�irsid:�'s' :dF�•'t aw. ''fla ,.. �a�,,`wa�,t.�..so*:.�:, j • Sender: Please print your name, address, and ZIP+4lin this box ° rti„ Town of Barnstab:e Health Division -4. 200 Main-Street ' cx>. Hyannis, MA 02601 I `I1'k�t�� 7��17F1 Ji�F�JJ,11FJ�l FJJ FFII.771f�1'�Ji11 t3FF7J�J.1.11 Fit/�i3F:S�FlJJ f 'Town of Barnstable Barnstable y�P Regulatory Services Department caN j * BARNSTABLE, • D 4A 9. Public Health Division AT fb MA1 a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL 7006 2150 0002 1041 7699 August 22,2008 Luiz M. Coelho 00 CAA G 48 Oak Hill Road Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located-at.24 Quaker Road; Hyannis was inspected on August 19, 2008 by Jaime Cabot, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a rental inspection. The following violations of the State Sanitary Code we•e-bbserved: 105 CMR 410.552 —Screens for Doors: No screen on French doors on deck. Downstairs storm door missing self closing device. 105 CMR 410.500- Owner's Responsibility to Maintain Structural Elements: Loose bricks on front steps. 105 CMR 410.551- Screens for Windows: Screens Missing from Windows. 105 CMR 410.501-Weather tight Elements: _ on w Broken. �— `"'----- 105 CMR 410.300 and 310 CMR 15.00: There were a total of Four(4) bedrooms observed in the dwelling. However the existing septic system was not design or four bedrooms. It was designed for three bedrooms. Li You are directed to correct the violations is e a y- o (24) hours of your receipt of this notice by removing the beds from the basement. r e You are ordered to correct the violations listed above within thirty (30) days of your receipt of this notice by pulling any required building permits to restore the property to a three bedroom home. You are ordered to remove the bedroom by removing entrance doors and by opening door-way entrance to the room to a minimum of five feet wide openings. This will bring the total bedroom count down from four (4) to the appropriate three (3) as designated by your septic permit. You have and thirty (30) days to place a screen in the storm door, fix loose bricks, put screens in the windows, replace the self closing device on the storm door and fix the broken window. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable cc: Health Inspector t FORM 30 H&W HOBBSB WARRENTM THE COMMONWEALTH OF MASSACHUSET.TS B AFRD OF HEALTH CITY/TOWN W �'CyA L t DEPARTMENT ° v 'Ir4y "I M� ` ADDRE S GSM 5v0�`0� c4b_ TELEPHONE Address QUftXA.& RO Occupant.LA-,/r U g4aa Floor Apartment No. No. of Occupants -� No.of Habitable Rooms No.Sleeping Rooms AV No.dwelling or rooming units✓ No.Storie Z Name and address of owner��L)_I L N b OAV, AiLU FZ_Q MA Remarks Reg. Vio. YARD Out Bld s.: Fences: V/ Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Lu- C-YI a fl-'uo accla1® Dual Egress:and Obst'n.. �T13 At-•M po a F_ �to CA- •hn�SL�� " 1 �Z ❑ B ❑ F ❑ M Doors,Windows: l.�fin. w /�rJC,e.�o ,o Roof Gutters, Drains: Walls: Foundation: Chimney: 2S� BASEMENT Gen.Sanitation: L es"C er'jTA- Dampness: Stairs: G lz►L� 0 . rep srep 4/0 SvG Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Li htin Hall Windows: p w S t Ste,i ti HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: d2_Q& I Al U ❑ MS ❑ ST ❑ P Waste Line: t-1 l H.W.Tanks Safet nd Vents Q ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 2-7 Bedroom 2 Bedroom 3 l 21 Bedroom 4 Hot Water Facil. S Stacks, Flues,Vents,Saf ies: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted 710 T zll Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES PERJURY." �f,f INSPECTOR TITLE '1 A 7G1 �N� 2, DATE f TIME `d ® a P.M. __T ellA.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises,shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in,any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to includeshall in no way be construed'as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,-.to meet the ordiriary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- m on area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. i (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. ' (J) The'presence of leadbased paint on a,dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health nor safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system'or any,part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as _ required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. J. `e=,..�''- �`r` '- ._,. . .-, .. ..r; ^^ta 4.u•sY-.g t..�,.rt�5;i a e-cw�, 3�� dP _ Date fl / 1 /0 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY ,t NAME OF BUSINESS: ` S, BUSINESS LOCATION: lmc�,��- gc::\,, L� � ' INVENTORY MAILING ADDRESS: _��1 TOTAL AMOUNT: TELEPHONE NUMBER: SGZ 1-\GG 515 7 CONTACT PERSON: RN EMERGENCY CONTACT TELEPHONE NUMB MSDS ON SITE? TYPE OF BUSINESS: �C - INFORMATION/R.ECOMMENDATIONS: 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 i 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 .t Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) 4 NEW = a 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 Io I I ` J A S (including bleach) y \\tr�� I I 5 a .� r f (10 Spot removers & cleaning.fluids (dry cleaners) Other cleaning solvents - e Bug and tar removers J Windshield wash s i1) WHITE COPY JHEALTH DEPARTMENT/CANARY COPY-BUSINESS v / Ig � TOWN OF BARNSTABLE Date:Ot\ /0 TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATIO Q \-\K �&� INVENTORY MAILING ADDRESS: , 5'c� TOTAL AMOUNT: TELEPHONE NUMBER: `25c,2 'AW g 05 7 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUM R: 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 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 1 I� rti a J nT� (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents e Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS r ' T 19 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP s l a PARCEL LOT TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 24 Ouaker Road Hyannis, MA 02601 Owner's Name: Geraldo Defreitas Owner's Address: xzT Date of Inspection: March 31, 2004 2, ., Name of Inspector:(Please Print) James M. Ford ' , �. Company Name: James M. Ford C). a� Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 — D Telephone Number: (508) 862-9400 r c� ttt` CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on'site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3111 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs er Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: April 4,2004 The system inspector shall sub t 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 ****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. I Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t CERTIFICATION (continued) 4 Property Address: 24 Quaker Road Hyannis, M4 F Owner: Geraldo Defreitas Date of Inspection: March 31, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: i i 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. I 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: I 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: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 Quaker Road Hyannis, MA Owner: Geraldo Defreitas Date of Inspection: March 31, 2004 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 I 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 Quaker Road Hyannis, MA Owner: Geraldo Defreitas Date of Inspection: March 31, 2004 f D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No 4 ✓ Backup of sewage into facility or system component due to 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 ✓ 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 '/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 SAS, cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 System: f To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 1?d• 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. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 24 Quaker Road Hyannis, MA Owner: Geraldo Defreitas Date of Inspection: -March 31. 2004 7 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this,inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum ? ✓ _ 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 r ✓ Existing information. For example,a plan at the Board of Health. j ✓ 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)). III I , 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 24 Quaker Road Hyannis, MA Owner: Geraldo Defreitas Date of Inspection: March 31, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: S 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): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: Qallons--How was quantity pumped determined? Reason for pumping: J TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Leach field added 214100-per as built card Were sewage odors detected when arriving at the site(yes or no): No 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: 24 Quaker Road Hyannis, AM Owner: Geraldo Defreitas Date of Inspection: March 31, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _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: ✓ (locate on site plan) Depth below grade: 32" Material of construction: ✓ 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: 1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 5" 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: 12" How were dimensions determined: Measuring stick 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 were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. Inlet and outlet covers were 5"below grade. GREASE TRAP: None (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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Ouaker Road Hyannis, MA Owner: Geraldo Defreitas Date of Inspection: March 31, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: alions/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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (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.): 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: 24 Quaker Road Hyannis, AM Owner: Geraldo Defreitas Date of Inspection: March 31, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2- 6'x 6'(1000 gal.) ✓ leaching chambers,number: 4-infiltrators 11'x 25'(per as built card) 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.): The original pit 04)was full up to the outlet pipe. The cover was 10"below grade. The newer pit(#5)had Y of water on the bottom. The scum line appeared to be up to the inlet pipe. The cover was 30"below grade. The leach filed infiltrators did not appear to show any signs of failure. CESSPOOLS: None (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: None (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.): 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: 24 Quaker Road Hyannis, MA Owner: Geraldo Defreitas Date of Inspection: March 31, 2004 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. A Deck Q a aa� . a� y 3 y 39.1 a9`° s 5, 39 vol (o y-7 30 .10 M Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Quaker Road Hyannis, MA Owner: Geraldo Defr-eitas Date of Inspection: March 31, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25'+/- 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: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: i You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximate!y 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. ]1 TOWN OF BARNSTABLE :— LOCATION SEWAGE # VILLAGE, ASSESSOR'S MAP& LO INSTALLER'S NAME&PHONE NO. �� SEPTIC TANK CAPACITY /�✓U LEACHING FACILITY. (ty (size)— //„1213_r NO.OF BEDROOMS BUILDER O R PERMPTDATE: COMPLIANCE DATE: 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 leaching facility) Feet Furnished by i cF o ! I f 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) d�e'As , hereby certify that the application for disposal works construction permit signed by me dated a—o') 60 , concerning the property located at Z:L4 av meets all of the following criteria: fib This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. 1/ The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. G/ There are no wetlands within 100 feet of the proposed septic system There are no private wells within.150 feet of the proposed septic system There is no increase in flow and/or change in use proposed ZThere are no variances requested or needed. ./ The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when /applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete 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 a �' SIGNED DATE: [Please Sketch p posed plan of system on back]. NOTICE � Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert p C,� � Q P Y' CO\BION«'EALTH OF MASSACHL;SETTS _ t EkECLTI TE OFFICE OF EN-VIRON-MENTAL AFF.AIP.;-, ,c -DEPARTMENT OF ENVIRONMENTAL PROTECTION O\E Ul\—MR STREET.BOSTON IN!A 0210c 16171 242-550ts _ TRH DT COX Secretan ARGEO PALL CELLtCCI DAVID B STP.-HS Governor Cotnnussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM MISPEC I ON FORM 21-23 Quaker Rd PART•A Hyann i s.,,Ma.0 2 6 01 CERMRCAnoN Property Address: Name of O mw McCormick Address of Owner: Date of Inspection: I—Ae 0-10 . Name of lmpector:(Please Print)Wm.E. Robinson Sr. I am a DEP approved system inspector to Section 15.340 of Title 5 1310 CMR 15.0001 Co,„p„tyN.: Wm. E . Robinson Sepat�ic Service MaiiingAddress: P6 BOX I0 9. Centerville MA Telephone Number: CERTIFICATION STATEMENT 1 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 inspection. The inspection was performed based on my training and-experience in the proper function and maintenance of on-site se disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails e Inspector's Signature: ICJ li � Data: 7—A (-•r L/U The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of competing 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 • � �ECEIVEO y S E P 8 2000 TOWNOFBMWBTABLE L� HEALTH DEPT. revise6 PaRviorn ati � t:J' ^+ed o^Reorird Panr• 5 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) NopertyAddress: 21=23 Quaker Rd., Hyannis , Ma. 02601 Owner: McCormick Date of Inspection: 7 INSPECTION SUMMARY: Check ®B, C, or D: A. SYS 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. 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. Indica yes,no, or not determined(Y. N,or NO). Describe basis of determination in all instances. If 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 (attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection: or the septic tank, whether or not metal,is 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 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 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 pipets). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised .9/2/58 Page 2of11 f' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icoftnued) Property Address: 21-23 Quaker Rd., Hyannis , Ma. 02601 Owner: McCormick Date of Inspection—�L 4 0--U 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(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) 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 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 1 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 d 1 I i re-v:se: 1`2Qc3of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21-23-Quaker Rd., 'Hyannis , Ma. 02601 owner: McCormick Date of Inspection: 7_X C_Gti D. SYSTEM FAILS: You ust 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 failure. Yes No Backup of sewage into facility.or system component due to an overloaded orelogged 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. 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 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. E. LA WE SYSTEM FAILS: You mu t indicate either.-Yes- or "No' to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health 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 ow er or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office the Department for further information. rev, sed 5 j 2�5 _ Pdgc 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 21-23 Quaker Rd., Hyannis , Ma. 02601t Owner: McCormick Date of Inspection: 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 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. _ As built plans have been obtained and examined. Note if they are not available with NIA. ✓/ _ The facility or dwelling was inspected for signs of sewage back-up. 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.N. _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) - 115.302(3)(b)JJ/ a The facility owner land occupants,if different from owner) were provided with information on the prapermainienaar�-0f Subsurface Disposal Systems. I i I , re, _se: 9/2/98 Page 5 of 11 I ' 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ►rop"Address: 21-23 Quaker Rd., Hyannis , Ma. 02601 owner: McCormick Date of Inspection: 't--dtG-o-o FLOW CONDITIONS RESIDENTIAL: Design flow: %.5 43 g.p.d./bedroom. Number of bedrooms�Idsn1:yl Number of bedrooms lactual):� Total DESIGN flow`? CJ Number of current residents: L Garbage grinder Iyes or no1:,�0 Laundry(separate system) (yes or no)AO If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no): /- v f //�� / Water meter readings, if available (Iasi two year's usage(gpd): (� m �J'�Q Sump Pump (yes or no): i 0 ff lU`Last date of occupancy: 2-2-4- ` u(Y �f//�Q� ./1 COM ERCIALfINDUSTRIAL: (¢ CA- Type establishment: Design low: qpd 1 Based on 15.203) Basis o design flow Grease ap present: (yes or no)_ Industri Waste Holding Tank present: (yes or no)_ •Non•san tary waste discharged to the Title 5 system: (yes or no)_ Water eter readings. if available: Last d e of occupancy: OTH • Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS�a/nd source of inf rmation/' System pumped as part of inspection: (yes or no)-g,0 If yes, volume pumped: gallons Reason for pumping: TYPE ref SYSTEM V 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other Q APPROXIMATE AGE of all components, date installed(if known)and source of information: �•� ` ✓(�� Sewage odors detected when arriving at the site: (yes or no),A.-- re%, sAu Gj 2/9E Page 6(if 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icmilimbed) lyop"A dies o: 21-23 Quaker Rd , Hyannis , Ma. 02601 Owner: mick Date of Inspection: 4--G-Q B DING SEWER: (Coca a on site plan) Dept below grade:_ Mate al of construction:_cast iron_40 PVC_other(explain) Dist ce from private water supply well or suction line Dia eter Com ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) I Depth below grade:j Material of construction:_�/oncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) ► v . ) Dimensions: I✓.. of I'a 10 C Sludge depth: CD y� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ �^�v Distance from top of scum to top of outlet tee or baffle: U L 1 1 Distance from bottom of scum to bottosp of outlet tee or baffle: l Now dimensions were determined: O ) �omments: Irecommendation for pumping, condition of inlet and outlet tees or baffles, depth uid level iryrelation to outlet invert, structural integrity, evidence of leakage, ep.l �'L� - �� L / GR SE TRAP: c at on sit(loe plan) Dept below grade:_ Mate al of construction:_Concrete_metal_Fiberglass _Polyethylene_other(explain) Dim nsions: Scu thickness: Di ante from top of scum to top of outlet tee or baffle: Di tance from bottom of scum to bottom of outlet tee or baffle: D to of last pumping: Com ents Dec mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid ce of leakage,etc.) =et i ccc Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART C SYSTEM INFORMATION(continued) •ropertyAddress: 21-23 Quaker Rd.., Hyannis , Ma. 02601 E Owner: McCormick Date of Inspections: TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) Iloca on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dim ens ons: Capacit gallons Design ow: gallons day Alarm resent _ Alarm evel: Alarm in working order: Yes_ No Date f previous pumping: Com ents: Icon ition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:` Comments: (note if level and distribution is equal, evidence of lid carryover, evidence of leakage into or out of box, etc.) PUMP C AMBER:_ locate o site plan) Pumps i working order: (Yes or No) Alarms i working order(Yes or No) Comme ts: Inote ndition of pump chamber, condition of pumps and appurtenances, etc.) reviSep- Page 8or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Addres : 21-23 Quaker Rd., Hyannis , Ma, 02601 OWfer: McG�ormick Date of Inspection: 7 dzG-�rU SOIL ABSORPTION SYSTEM(SAS):, (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: i Comments: Ino ondtio f spi�signs of hydraulic failure, level of pondin damp soil, co dition of vegetatjpn, a .1 u C SPOOLS:_ Iloc to on site plan) J Numb r and configuration: Depth- p of liquid to inlet invert: 7epth o solids layer: I lepth of scum layer: IDimensio s of cesspool. :Materials Df construction. Indication of groundwater: nflow (cesspool must be pumped as part of inspection) Comme s: (note c dition of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc.) PRIVY: (locate n site plan) Material of construction: Depth o solids: Dimensions: Comme ts: Incite cc dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) --------------------- pig( 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ''ropertyAddress: 21-23 .Quaker Rd , Hyannis , Ma, 02601 ,weer: McCormick - Jate of Inspection: -7 t-a.(>'`do00 SKET H 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 house) 0'0wckca- R.O\q'D a sssit Q -- - - _ - -- o 1P Pagc 10 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION lcontinuedl rop"Address: 2 1-2 3 Quaker Rd., Hyannis , Ma. 02601 Owner: McCormick Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Deep Groundwater depth: Shallow Moderate SITE EXAM Slope Surface water E Check Cellar Shallow wells 61. t Estimated Depth to Groundwater /✓ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record i Observed Site (Abutting property, observation hole. basement sump etc.) p � Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators. installers _ Used USGS Data i Describe how you a tablished the High Groundwater Elevation. (Must be completed) L & .l , cv.Sec CJj L%y� page iloril TOWN OF BARNSTABLE � CG LU" ...1:E),,. u / SEWAGE # ,LAG E ASSESSOR'S MAP_&� LO LN-TALLER'S NAME&PHONE NO._ /y1i Cic�/Y� � 7_ c 22 E-C7 � SEPTIC TANK CAPACITY _Z!f&0 :ITY: _ i LEACHING FACII (tyke) /�vi/�/>/.�1` (size) NO.OF BEDROOMS ` 1.'3UILDER OR WR- on _ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Suppiy Well and Leaching Facility (If any wells exist 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 *f' o.At C e Y 3 I f ' 1 f e i a) R r' TOWN OF BARNSTABLE LOCATION 1 QU��•� '`� SEWAGE # VB.LAGE -A11Ay) 15 ASSESSOR'S MAP & LOT3�0 aq INSTALLER'S NAME&PHONE NO. �i SEPTIC TANK CAPACITY CJW ^1L .LEACHING FACILITY: (type)a' (eX(o P 4S !M (size) NO. OF BEDROOMS 3 BUILDER OR OWNER GGrAlI O PERMITDATE: COMPLIANCE DATE: 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 leac ng facility) Feet Furnished by 1 r►f� 'y^ �. Fe/� W y.) -mac vt v 41 w v s� c 7r W No. �^ /",\\ 9' Fee �f THE COMMONWEAL �/— TH OP MASSACHUSETTS �1 Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migoof *psstem Construction Vermit Application for a Permit to Construct( )Repair( )Upgradel)Abandon( ) ❑Complete System Yindividual Components Location Address or Lot No. y Q��✓ Owner's Name,Address and Tel.No. Assessor's Map/Parcel �® Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1 45;;� ` d J% S -S 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 `tea D gallons per day. Calculated daily flow V\S) gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank <L r c,±:�= l07'V Type of S.A.S. C Q A-'e rc� da Description of Soil; lArc. Nature of Repairs or Alterations(Answer when applicable) �SY�� ctir,/rtG 2.- cVXrr'''tt�`� 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 n Issued by t is e th. Signe _ Date Application Approved by ✓ X Date Application Disapproved for the following reasons Permit No. Date Issued No. 20 oro 1((/ f� ,�"\} Fee! —0/ -� s Entered in com uteri THE COMMONWEAL --MASSACHUSETTS p .. - Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ' Y 01pplication for Miq;pogar *p$tem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade V)Abandon( ) El Complete System [N4ndividual Components Location Address or Lot No. Z y Q�/��+�" Owner's Name,Address and Tel.No. Assessor's Map/Parcel 'Obw I II Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. \'� ` d�,1+ S S 1 • BSc*-� �,.ti�.c.-+ S 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 O gallons per day. Calculated daily flow \A S, gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank t(7 d O Type of S.A.S. 0,c (cab t t c,,.au ea Description of Soil 'Nature of Repairs or Alterations(Answer when applicable) bLST Date last inspected: -04 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 n issued by this eI th. Signed Date Application Approved by Date ? Z-ZM-0 Application Disapproved for the following reasons Permit No. - 6 Date Issued --------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(w< Abandoned( )by `r —C. L S tC.- (T at =_ G, V has been constructed in accordance with the provisions of Title 5 and the for,Disposal System Construction Permit No. Z. W 6 !f dated, Z.:7 Installer Designer The issuance of this permit shall not be construed as a guarantee that the system,will function as esigned. Date Inspector --------------------------------------- No. ?ftY`dU ' t0 Fee 310 2 q / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mioogaf *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at -`~� ��. 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 permit. Q Date: Z -4/Ze� Approved b A o Sri✓ t,, I Y �! yes- 0 l00 TOWN OF BARNSTABLE L(i :ATION LJ SEWAGE # 01- 4-AGE ASSESSOR'S MAP& LOT2/a~ INSTALLER'S NAME&PHONE NO. 7 76--2 776 SEPTIC TANK CAPACITY LEACHING FACILITY: (type)) /fly A/ C (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 7/3 COMPLIANCE DATE: 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 leak ng/facility) - Feet. Furnished by s r w 4 AGSWORS No. PARCIN0: Fee 40 .00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[pp ration for Mizpoaf *pgtem Cow5trUCtion Permit Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 21 -23 Quacker Rd MR. McCormic Hyannis MA P.O. Box 2378 _ Installer's Name,Address,and Tel.No. WXiiRG19R&e,CA&reQ 0 fiONo. W.E. Robinson Septic Sery P.O. Box 1089 . Centerville 775-8776 Type of Building: Dwelling No.of Bedrooms 4 Garbage Grinder(no) 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 Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install a 1 , 500 Q a 1 septic tank, d-box and 4 stonepacked infiltrators. 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 issue by this 139ard o ealth. ? Signed i Date —✓ Application Approved by Z Application Disapproved for the following reasons Permit No. :;z Date Issued "' J""` � } ....-:%.• �� A ! ..�.: .:.�.-;-`, - .- ...:��..�i��o-.:.•,,,:.rr ,�","'.�� -✓."�'; ♦.y„�4"zt� ,MF:S*r:.: h, /�J( m:Z-;' r _;,�. N•-"-�f ..•.4�.. �.. �..: Fee40.00 No. " _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLEs MASSACHUSETTS 0[ pYtcation for &&pour *pztem Con!5tructcon Permit Application is hereby made for a Permit to Construct( )'or Repair.( -x)an On-site.Sewage Disposal System at: ' Location Address or Lot No. Owner's Name,Address and Tel.No. 21 -23, Quacker Rd MR. McCormic Hyannis MA P.O. Box 2378 6-5 Installer's Name,Address,and Tel.No. ��si r�9� he,S'4�re�CIONo. .W.E. Robinson Septic Serv. P.O. Box 1089 Centerville 775-8776 Type of Building: Dwelling No.of Bedrooms 4 Garbage Grinder(no) Other. Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow gallons per- 'ray;-.0 culated daily flow - gallons. Plan Date Number of sheets Revision Date Title Description of Soil . sand Nature of Repairs or Alterations(Answer when applicabl in tall as 1 500 al septic tank d-box and . 4 stonepacked. inf il atd'rs. Date last inspected: Agreement: -_—.4he=unI.dersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system '> j in accordance;with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- r Vcate of Compliance has been issueo by this Bgwd o 'ealth. ? Signed Date `, Application Approved by f . Application Disapproved for the following reasons ; - I t i Permit No. " % L Date Issued —� .. � .�,--s-�.e.=ter — --——-��>--�=�..�——�———— ----�. ` ----��- � _�•. THE COMMONWEALTH OF MASSACHUSETTS • . I PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY that the On-site Sewage Disposal Syste installed( )or repaired/replaced X )on by W.E. Robinson Septic Sery -21 -23 Quacker Rd Hyannis as for Mi. McCormic* has been constructed in accordan e with the provisions of Title 5 and the for Disposal System Construction Permit No. dated / Use of this system is conditioned on compliance with the provisions set fWk below: y' k ��.��L^^a S�im�•�P'i�' 4a�avO��a��iY�®-G�.��P'i ��^T�:'��—T.� 40.00 No. .� Fee i McCormic THE COMMONWEALTH OF MASSACHUSETTS ShorelanOUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wigpogar *p.5tem Con5teuction Vermit Permission is hereby granted to W.E. Robinson Septic Service to construct( )repair(X )an On-site Sewage System located at 21 -23 Quacker Rd Hyannis . i and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to j comply with Title 5 and the following local provisions or special conditions: j i All construction must be completed within twoyears of the date below. Date: Approved b � �% �% CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, At",d�6�� , hereby certify that the application for disposal works construction permit signed by me dated '�^3 9 , concerning the property located at el 01 c �"( c�-1 meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system \ • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: l/li i /( DATE: , LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. r 4 r ,le C3 v f . 1 i TOWN OF BARNSTABLE BAR-W 14`28 Ordinance or Regulation WARNING .NOTICE, Name of Offender/Manager VG.1 Address of .Offender, MV/MB Reg.# j Village,/State/Zip cc .�o _ .#. Business Name �am pm, on 0 .'19J6 Business Address OAAA-A IM �/�/1 Z A(� Si nature o.f Enforcin Officer g g Village/State./Zip Location of Offenses Enforcing Dept/Division Offense N yt..SQ,i'-Ct (�-�i(�(C-It /6A / Facts 7 �� I h far Gd'l Ce This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve -voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in. appropriate legal action by the Town. Ci vwp G.f w / ,p7 r `.Y TOWN OF BARNSTABLE BAR.-W 2 . Ordinance or .RegulationvA, WARNING NOTICE Name of Off ender/Manager ' l—'L-1' 4 ,) '` r r° Address of-Offender � � ��.�- � _.' �`�" �' MV/MB Reg,# Village/State/Zi i 1 .;{ - 4Business Name am/pm, on 0 : 19 {.- Business Address: t« ` ? : If".(4_e, r, { Signature of Enforcing Officer Village/State/Zip t Location of Offense Enforcing Dept/Division Offense ulscbA("r Facts ? !_ `""� fit I _ `>s ;r.. �.F - �fc ' This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. ,