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HomeMy WebLinkAbout0080 QUAKER ROAD - Health 80 --QUAKER RD.;.�HYANNIS A=310-298 — `/ o r r I I` o / /� / a � TOWN OF BARNSTABLE Date:07 p) TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: Ren"4 )5 ele an`ingl c ►rvi c� `�Gs- IS"�k A-T t b A( BUSINESS LOCATION: INVENTORY MAILING ADDRESS: 8n a ta y Rd l n iS MQ pa 01 TOTAL AMOUNT. TELEPHONE NUMBER: Spa • Zq -3g36 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: eicaninQ IN FORMATION/RECOM MEN DATION& 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 I rine Battery acid (electrolyte)/Batteries Lye or caustic s©tl/ Rustproofers Miscellaneous °Tmbustibl p Car wash detergents Leather dyesl�r Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's �. Paints, varnishes, stains, dyes Other chlorinated hydro on Lacquer thinners (including carbon tetrach oride) i ❑ 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 lil A WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials I Date:Oq /0,? / i O TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: Rpnn-®'5 (21P= P BUSINESS LOCATION: Homes INVENTORY z-�,!�MAILINGADDRESS: RO &,oKer R i nntS mn CO0GO/ TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: R-Pnc c+ck EMERGENCY CONTACT TELEPHONE NUMBER: 116•(,,n�`7 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) Q _ 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) 0 Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED 0 Degreasers for engines and metal (0 Printing ink Q Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout 0 Swimming pool chlorine Battery acid (electrolyte)/Batteries 0 Lye or caustic soda 0 Rustproofers v Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes 0 Fertilizers Asphalt & roofing tar O PCB-s Paints, varnishes, stains, dyes 0 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 0 Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) 0 Other cleaning solvents Bug and tar removers (9 Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN OF BARNSTABLE SEWAGIr?0 7 .VILLAGE /3�}z/�:.rY/(= ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO.. ( /ddi L Ct`�'Q `l/ �� V�-07-2 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size)J -',J( y 3 X - NO.OF BEDROOMS OWNER PERMIT DATE: 7 —> 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 leaching facility) / Feet FURNISHED BY ��� ���p �✓✓/� AV ., `v 0 1 am. H R _ Ilk w W Mho z9ST Fee r THE COMMONWEALTH OF MASSACHUSETTSn.0 Entered in computer: UBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Of ppYtcatton for BtqaaY 6p5tetu Cott0truttton Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑.Complete System LJ Individual Components Location Address or Lot No. ff �,U Owner's Name,Address;and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building ­2'40,0 ., ' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Z11—r0 gpd Design flow provided gpd Plan Date 7-- -S' — 0 7 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provis}ons of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boa ealth. Signe Date 2_ w�� Application Approved by Date Application Disapproved by. Date for the following reasons n Permit No. Date Issued • •- - �• . _ •.�. .. >_�7,� No. .i� L �, Fee . .... THE COMMONWEALTH`OF MASSACHUSETTS Entered in computer: Yes UBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zlophcation for �Ngpogal i�pgtem Cowaructiou Permit Application for a Permit to Construct O Repair( eUpgrade'( ) Abandon .Complete System [ Individual Components '! Location Address or Lot No. 6?4'Vo e' Owners Name,Address;and Tel.No. Assessor's Yap/Parcel Installer's Name,Address,and Tel.No. DeLgner's Name,Address and'Tel.No. i „Type of Building: "t Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building /l'G""f' No.of Persons Showers( ) Cafeteria( ) ,t Other I,ixtures Design'Flow(min.required) �rG gpd Design flow provided6� gpd Plan Date Number of sheets Revision Date t> - Title Size of Septic Tank _ Type of S.A.S. Description of Soil o 's { Nature of Repairs or Alterations(Answer when applicable) ; I � j f4. Date last inspected: Agreement: ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions,of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boa ealth. Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons " t - i Permit No. Date Issued —————————————— ———————————— —- ----------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compitance _� I THIS IS TO CERTIFY,that the On-site•,Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( ) Abandoned( )by at eP O Gt yit . ,0V,9!5, I0"y, has .een<co s ucted' ecordance07U _ with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer ,��/y! L4e�30E Designer 46 !iZ-d OVA/ #bedrooms n� Approved design flow gpd , The issuance of this permit shall not be construed as a ua ante that the system wil nc i as d� ned. Date Inspector J � ————————— RT�FE - ———————————=———————————— No. Fee COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Otsspogal 6pgtem Cow5tructton Vermtt / Permission is hereby granted to Construct ( ) Repair ( �Upgrade ( ) Abandon ( ) System located at 1P O Q y�,4,�GG"G�'i //ems looiM 1✓-V f le! V14 . 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 m k be completed within three years of the date of this6eYm)4t_ Date Approved by :'7 04: zzp P. 1 t Town Of Barnstable :o�iiue, Regulatory Services i(a 1 ° Thomas F.Genler,Director v��]�A$ F.aEM = Public Health Division � � A !;� �e Thomas McKeao,Director 200 Main Street,Hyannis,MA 02601 i Fax: 508-790-630e C)tf�c: 505-962-4644 installer &Designer Cerfifcation Fortin Installer: Address: i;►n -�vo l �' �^ -was issued a permit to iA.stall:i (date) (rmstaller} ,efrdc system at based on a design drawn by (address) � uAIZ-j dated - (desigaer) 1� -certify that the septic system referenced above was installed substanti4ly according'to --- ; e design, which may include minor approved changes such as late? re di location. c'f the distribution box and/or septic tank_ I cextify..t]aat the septic system refer above was installed with' r change:: --1-- gxeater Ilia n 10' lalteral relocation of the SAS or any verfical'reloaation of any corq)t)ncnat of the sep��,Vstem)but in accordance with State &I•,ocal:Rogdilations. Plan revisi-Du or certified as bui�jby designer to follow. H®F�1gs VIO , Co (Installer's Signature) "2 MASON T v. 9 No.'taw O — �Q�9TENG• !� N17AW c • ayr s Stamp Here) • (lie 's ignature) (Afkix ]��,SE ')CUIN ':C® $ S'i<'A&l.E PUBLitC ]EI]EAf.TH DfV[SllO RTITIC:A,TC OF C®M -LIANCT, 1l�ILl.'N1 O SEM UED, BOTH-=1W[S 1FORM .APff T T Ca�tD ARE)[BEC fl D-81(THE.B STAALE FUBLI ; HE ' AJ[i�Ik�,:1.ON. RUBQ:'Hca1t1VScptirJUc irncr cerificaEion Form i 1 Town of Barnstable P', Department of Regulatory Services ? ,Public Health Division Date r ib . 200 Main Street,Hyannis MA 02601 patenScheduled Time Fee Pd. Soil Suitabiliityy� Assessment for Sewage Disposal Performed By: D V/D /��o�til Witnessed By:"�-� l � 441 LOCATION& GENERAL INFORMATION A/ Location Address �© Owner's Name / � ' !Y I _y_Zv_/ : Address -/ ' Assessor's Map/Parcel: 3/o r �9� ) Engineer's Name�k/� P 7� NEW CONSTRUCTION c. -'- REPAIR Telephone# Land Use �' ' ' "� Slopes(g'o) / Surface Stones ' Distances from: Open Water Body 1"/''A ft Possible Wet Area "/ft Drinking Water Well 6�4 ft Drainage Way ,v ft Property Line t ft Other �— ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands?n proximity to holes) �I „ r r J� -� /00 Parent material(geologic) �t//w 4 Depth to Bedrock Depth to Groundwater: Standing Water in Hole. `N Weeping from Pit FAA Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level,.-,.�...�.,. Adl.factor �T Adj.droundwater level PERCOLATION TEST mute Thne Observation ' Time at 4" Hole# i Depth of Perc v Time at 6" - Start Pre-soak Time @ Time:(9"-V) End Pre-soak GZ IA�U, / Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) original: Public Health Division Observation Hole Data To Be Completed on Back----------- 1 ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil - Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. o isle ravel DEEP OBSERVATION HOLE LOG Hole#_ . Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) t (USDA) Other (Munsell) Mottling (Structure,Stones,Boulders. Consis DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) Other (Munsell) Mottling (Structure,Stones,Boulders. Cnitec vel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in:) Other (USDA) (Munsell) Mottling ;(Structure,Stones.Boulders.' r Consi t n 1[— Flood Insurance Rate Maly / Above 500 year flood boundary No_ Yes v Within 500 year boundary No P Yes Within 100 year flood boundary No!� yes Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �S I If not,what is the depth of naturally occurring pervious material? i Certification I certify that on �` (date)I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience de cribed in 310 CMR 15.017. Signature Date c� Q:\S.EPTlC1PERCF0RM.DOC f TOWN OF BARNSTABLE LOCATION �� �l�Q�(G�'/` !^ G� �j SEWAGE # VILLAGE � /? ' ASSESSOR'S MAP & LOT-2Ze Zug INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /S`dd G"L LEACHING FACILITY: (type) L-�, �Z_(size)/rl, 'g Se' NO.OF BEDROOMS 5- BUILDER OR OWNER Ve V PERMIIDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 52" 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) AnFeet Furnished by ! i R�r I ds i - i J s"d` �wsvnfrar/ N. l/ 3lD Z Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE,MASSACHUSETTS Zlpplication for Oigo$al 6p$tem Con$truction i3ermit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) Complete System Individual Components Location Address or Lot No. Tv /9 //y ji p�f 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. �0/�Co�1Go�6� 7T/-?3p9 Type of Building: Dwelling No.of Bedrooms IS Lot Size sq.ft. Garbage Grinder(_01 Other Type of Building e�Y�No.of Persons Showers( .) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /5-00 Type of S.A.S. /�•ZS-X SD X Z Description of Soil Nature of Repairs or Alterations(Answer when applicable) /fie /�` TD �r>•9 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b s oar i of ealth. Signed Date ? S/P Application Approved by Date 9,1 Application Disapproved for the following reasons Permit No. " Date Issued ------------------ - - - ---- - --- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CEIWI Y�t t he O site ��s isposal System Constructed( )Repaired(v)Upgraded( ) Abandoned( )by P z, i l at FD Gg L/Q,C /`� lf/�/�/5 been cons ed in p/cord pc�. with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit hal JgotVe o�tstrped as a guarantee that the sytem-will fun on as designed Date �" l�/9 y Inspector ,4 t, f".�- >. -- _ _ — __ _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Migpoal 6p2tem ;;de n5truction permit Permission is hereby granted to Construct( )Repair ) ( )AbandonSystem located a[ am�� S 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:Co ction must be completed within three years of the date of thi t. ^�� --y Date: ` //� ��b Approved by i" _Y P. 1 COMMUNICATION RESULT REPORT ( JUN.25.2007 10:27AM ) TTI BARNSTABLE BOARD OF HEALTH FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE -------------------------------------------------------------------------------------------------------- 199 MEMORY TX 915087751074 OK P. 2/2 ----------------------------------------------------------------------------------------------------- REASON FOR ERROR E-1) HANG UP OR LINE FAIL E-2) BUSY E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION o sepi F I IT w\b J R .wy �e TOWN OF BARNSTABLE LOCATION gd 414( Afr �� SEWAGE # S pl VILLAGE ASSESSOR'S MAP & LOT .�% 7— INSTALLER'S NAME&PHONE NO. Ado"7P ST SEPTIC TANK CAPACITY /Sod ee;ve LEACHING FACILITY: (type)�yd'l 6�� (size)/D�.s''yC fdo',It,a NO.OF BEDROOMS ' BUILDER OR OWNER /you 5 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Sf 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 No5"'ek'1 2i p S�•o/ °I95 q Sh . s4 O y� TOWN OF BARNSTABLE _ I,'OCA=N 6,0 94(aAe?- I^G , SEWAGE # 4'ILLAGE �IPM{9J°S ASSESSOR'S MAP &LOT D�-ZAg INSTALLER'S NAME&PHONE NO. /Sod SEPTIC TANK CAPACITY ° LEACHING FACILITY: (type)��el'C (size)/0'.2s NO OF BEDROOMS BUILDER OR OWNER yDh S PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S 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 --,,II within 300 feet of leaching facility) AAA Feet Furnished by 0 � ' F r � y yr, - 310—Z�� = No. �f` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migpogar 6pgtem Congtruction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ElComplete System UK Individual Components Location Address or Lot No. /')i //y � �r Owner's Name,Address and Tel.No. D !1r Vial ' �l�� r'� Gy®ems Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/ Other Type of Building t° bg'_^�No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /`ip gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. « �✓`'-.?' S7>'�' Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue4bhis Voar.JoLHealth.SignedDate Sl Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued '� tee THE COMMONWEALTH OF MASSACHUSETTS _ Entered in computer: 1 Yes "PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01pprication for Migpogar *p5tem Construction Permit Application for a Permit to Construct( )Repair(y )Upgrade( )Abandon( ) ❑Complete System KIndividual Components Location Address or Lot No. Q'� r Owner'�Name,Address and Tel.No. Assessor's'Map/Parcel /QU �, Installer's Name,Address, D d TeI.No Designer's Name,Address and Tel.No. �ryv�o�'f 71'/- spy' Type of Building: l Dwelling No.of Bedrooms v42 Lot Size sq. ft. Garbage Grinder(_IT Other Type of Building e l4K -No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /5 -X/S�/�9 Type of S;A.S. Description of Soil 7 ,J. Nature of Repairs or Alterations(Answer when applicable) � �� d Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi cate of Compliance has been issued b his oar o ealth. - Signed Date i Application Approved by Date Application Disapproved for the following reasons l Permit No. ! Date Issued THE COMMONWEALTH OF MASSACHUSETTS 3/ BARNSTABLE, MASSACHUSETTS y Certificate of Compliance / THIS IS TO CElj�IFY, that jhe On-site S� Disposal System Constructed( )Repaired( v}Upgraded( ) Abandoned( )by `f r'7L�(�, 1 C J� at as been cons end in,�`ordance,,y. with the provisions of Title 5 and the for Disposal System Construction Permit No. ° dated 1 j Installer Designer / The issuance of this permit shah of e o s , ed as a guarantee that the y'.tem will function as designed d Date JI /> Inspector 1C)/ /y�•1�— , ra E No. � /9 ----------------���l��g----Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mi!5pogar *pztem on5truction Permit Permission is hereby granted to Construct( )Repair )U• rade( )Abandon( ) System located at 9-,/ 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 m st be completed within three years of the date of thi ol `t. Date: (/„ Approved by l i 1 .4 10l9/97 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 ENGINEERED PLANS) 1, ®�j�f1f7�`o7, hereby certify that the application for disposal works construction permit signed by me dated Ala� , concerning the / e property located at yyan,41-11-5 meets all of the following criteria: /T ere are no wetlands located within 100 feet of the proposed leaching facility /There There are no private wells within 1-40 feet of the proposed septic system is no increase in flow and/or change in use proposed /IFthe a are no variances requested or needed. proposed leaching facility will be located within 250 feet of any wetlands, the bottom or the proposed,leach in facility will IIQt be located less than murteen (,1-,) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map.) B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: 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]. q:health folder.art t0/9/9t 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 ENGINEERED PLANS) I herebv certify that the application for disposal works construction permit signed by me dated concerning the property located at meets all of the following criteria: • There are no wetlands located within ioo fee:of the proposed leaching facility • There are no private wells within ! 0 fee:of the proposed septic sysre.m • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • if the proposed leaching facility wiil a located within__50 fee,of any wetlands.the ooaom of the. proposed leaching facility will pot be iocated less:han fourteen i,!-1 feet above the maximum adiusteq groundwater table elevation. Please complete the following: g to the Engineering Division G.I.S.mapi A)Top of Ground.Elevation(accordin B)Observed Groundwater Table Elevation(according to Health Division well map) - i SIGNED: 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]. ¢eedth folder.art f i re Li Ste' Y I vV _ Q ASSESSORS MAP : TEST HOLE LOGS NOTES: ofe FLOOD ZONE: ►,, r ,ICl.- ,. _ . .._ - .....M.x .ww-. , �YI'L � SOIL EVALUATOR . WITNESS 1 t ��;,*�f�.� 1) The installation shall comply with Title V and Town of Barnstable Board of �.... .*tV4� 5��� C"p 49 DATE: Il r t REFERENCED �. .,�J _� 2) The installer shall verify the location of utilities, sewer inverts and septic r � Health Regulations. PER COLAT I Ot�+ RATE• ,�[. components prior to installation and setting base elevations. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first w ... _. ..� TH 1 TH-2 ` � ) two feet out of thud-box to the leaching shall be level. y t� 4 This lan is not to be utilized for ro ert line determination nor an other ► ! purpose other than the proposed system installation. Lp l y Iwo 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H10 septic components. 7) The property is bounded by property corners and property lines. LOCAT ION MAP(�-�'.T",�� M.�, �u�-t�:� 1 ►�tr� t +tvv G i ,� � 8) The property owner shall review design considerations to approve of total 2t _- design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed .� 7t''�bC� (1 , � approval of the design flow by the owner. s ^ ` Z 2► � .1,51 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be AID t 1 1 removed along with contaminated soil and replaced with clean washed sand HD CW40, 1�4=1£k� � Plta 404). Wq& per Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEP I C SYSTEM DES I GN . .- a' applicable. : H�✓ 7- 6 ,7 j " ` - 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. • "' FLO4 ESTIMATE 1.2)The installer is to take caution in excavation around the gas line if applicable. 50 A AY 13) The leaching components are rated for H2O. 01 jqj a, io ' BEDROOMS T HO GAL/DAY/BEDROOM •Jr G L/D {D O O SEPTIC TANK �-4 J'r r GAL/DAY x 2 DAYS - //06 GAL /500GALLON SEPT i C TANK 0"x/5774 1-19'47H 131' �`o I _ ABSORPTION _ ,.., r _. 1 \� SIDE AREA. X �Z �`- 12,�33 2.k► 'Z ( BOTTOM AREA: X2 / x , W. 39 / • J ` , N Q y 'PTIC SYSTEM SECTION q,.I Off � Ila ( ` $14t a� 45bo , GAL Z. SEPT1 C T NKs' -( � � ""=t. ► j°�S► . WAStX? t1 ... fL:. _ Q SITE AND SEWAGE PLAN LOCATION : ! FDA D PREPARED FOR : SCALE: , zo DAV I D ` B . MASON,'RS DATE: 5 z DBC ENVIRONMENTAL DESIGNS z EAST SANDWICH . MA W DATE HEALTH AGENT SOS ) 833- 2177 Z