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HomeMy WebLinkAbout0101 QUAKER ROAD - Health _ 101 Quaker Rd aka 101-103 Quaker Rd �ji► 310 1 I J�Town of Barnstable P# l n16 AWE Department of Regulatory Services . aAPIMBIZ: Public Health Division Date 6 MASS. �� 200 Main Street,Hyannis MA 02601 � ✓ Date ScheduledAM Time Fee Pd. Soil Suat�li sse sment�r Se 's s l Performed By: Witnessed By:� LOCATION&GENERAL INFORMATION Location Address lot C' yU A KCV � Fdyj�ddresswners Name �e'S Q F V`rT `C�1JG h aJl 1L,v Assessor's Map/Parcel: �i©/s�� Engineer's N.7 q��/ r� NEW CONSTRUCTION REPAIR Telephone#d r Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) �I Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date Time Observation Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-V) End Pre-soak - Rate MinAnch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***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 r DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other - Surface(in.) (USDA) - (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) - (USDA) (Munsell) Mottling (Structure;Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv:%Gravel) Flood Insurance Rate Mao: q/ Above 500 year flood boundary No Yes (� Within 500 year boundary No ,!5�es Within 100 year flood boundary No Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi us at al exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth turally occurring pervrial? Certification I certify that on (date)I have passed the soil evaluator examinati napproved by the Department of Envirotal Protection and that the a ve analysis was perfo d b me consistent with the re g,expertise an erie esc bed� 0 CMR 15.017. ff Signa Date Q:\SEPTIC\PERCFORM.DOC TOWN OF BARNSTABLE 11 OCATION /()/ J�/OJ NUtJ K-Cf, le& SEWAGE#v20 VILLAGE ASSESSOR'S MAP&PARCEL-���3�� INSTALLER'S NAME&PHONE NO.(.//4,fQ, ,4.4C 6,?fE r SEPTIC TANK CAPACITY �4/1pw r4v?le f //cvt TJ?171(- LEACHING FACILITY:(type) 9/1//� i� NO.OF BEDROOMS ✓'��_� OWNER WUS7 PERMIT DATE: g'�°Lo f Z.o 1`f COMPLIANCE DATE: ` Separation Distance Between the: f' 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 C3- �a ch O �s y No. 2-C.MMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH I �yq OF APPLICATION FOR DISP ,SAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components )ID UAW 1 l6q+W q(2Jq-eV IL46 Lcv&- ZqRr., " ap/Parcel# t �—Address —�--0— Lot# �� �TelepM Installer's Name Designer's Name 6-(26A s. Address —Telephone# Telephone# Type of Building: 1 k-/ Lot Size Pt'b& K—Sq.feet Dwelling—No.of Bedrooms 44 M I Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.re ired) gpd Calculated design flow gpd Design flow provided r gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) -, Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation v DESC�IP� AO ON OF REPAIRS AIRS OR ALTERATIONS L29Ygk—O'7114 3- Z7> 7,�- I C04t"5 The undersigned agrees to install the above described Individual Sewage Disposal System in accordari with the provisions of TITLE 5 and.further ag9ps not to place th ste in operation until a Certificate of Compliance has been ssue by the Board of Health. Signed e FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 F O— E'COMMONWEALTH OF MASSACHUSETTS •_ x FEE --� D `:aJ BOARD OF HEALTH O F APPLICATION.FOR DISPO L SYSTEM CONSTRUCTIO Sy. N'PERMIT Application for a Permit to Construct ) Repair ( Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components i ap/Parcel# —Address 1 Lot# C776 TelepoC+tla �� J Installer's Name Designer's Name i Address i Telephone# Telephone# i Type of Building: 1, Lot Size Ot'JS KSq.feet I Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures i Design Flow(min.re fired) gpd Calculated design flow gpd Design flow provided rgpd Plan: Date ZD �' Number of sheets Revision Date LT Title Description of Soil(s) �- -' Soil Evaluator Form No. Name of Soil Evaluator t Date of Evaluation O i DE/ TIO�T OF FAIRS OR ALTERATIONS I i (I� -• f —D I' The undersigned agrees to install the above described Individual Sewage Disposal System in accordan with the provisions of TITLE 5 and further ag s not to place the ste in operation until a Certificate of Compliance has bee�nssuo by the Board of Health. Signed .� e / o d s 6 9 � Kt I� FORM I - APPLICATION--FOR DSCP DEP APPROVED FORM 5/96 q:v .-0�'t�.m as ,r.r s�a..w ae•e�.�a m wv oe -.r o u�,u.'r+:'w m av asau-eK.W MJ.Ga+-iae-vc.Az�.er uu �o rt��: ) as cr o�r.�. I� s No. +� HE COMMONWEALTH OF MASSACHUSETTS FEE ✓✓ - BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Seew''ag''e Disposal System;Constructed( ),Repaired Graded( ),Abandoned( ) by, iG"NG�V In-I1G� L- 14�J 0 at has been installed in accordance wi he y tons of 310 CMR 15.00 (Title 5) and the approved design ns/as-built plans relating to application No. tea d Approved Design Flow (gpd) Installer CI` r 1y� 411aInspector to Desi ner: \)1D y" 4 i The issuance of this certificate shall not be construed as a guarantee that thsystem will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 I No. E COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONS,TT�JCTION PERMIT Permission is hereby gra led to Constru t Re air rade ( ) ba don a individual sewage ,I disposal system at I Ina , s as described in the application for Disposal System Construction Permit No. dated Provided: Co tr do ishall be completed within three years of the date of this pe it. 1 c diti ust be met. Date 1 Board of Health 1 + FORM 2 - DSC DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON i Town of Barnstable y�Ft►�r Regulatory Services Richard V. Scali, Interim Director • sn[ttvsrnBM + Public Health Division zb39. �0 '''fo►�+° Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Far: 508-790-6304 Installer & Designer Certification Form Date: to , v 1 Sewage Permit#16 iq_3 22---Assessor's MapTarcel Jib -j Designer: 1,�° k Installer: O 1IA"� , �� ' Address: �i � lL�-� Address: h � r On / S l�`i`(a���'1h �• was issued a permit to install a date) (installer) n septic system at sed on a design drawn by dress) WA�n4dated I-101 (designer) i/ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer.to follow. Strip out (if required) was inspected and the soils were found satisfactory. I cerp that the system referenced above was constructed ' nce with the terms f t e IAA approval letters (if applicable) ��10F��ss /v DAVID 9��\ r Q 'J ( nstaller' °gnature) MASONS �o PJo.1066 GO' (Designer s Signature) (Affix Desi p& p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- . BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$30.00 for 4.years). A business certificate ONLY REGISTERS YOUR NAME in town [which you must do by M.G.L.-it does not give you permission o ope a e.) Business Certificates are available at the Town Clerk's Office, 1'FL., 367 Main Street, Hyannis, MA.02601 [Town Hall). DATE: 1(/QjLZ00G �n5 Fill in please: 11 i € ,720 man s� < � � § �� APPLICANT'S YOUR NAME: Ir o5- 1AV-C1\-JC-1S. Nna BUSINESS YOUR HOME ADDRESS: v� S - �� ,,..k TELEPHONE # Home telephone Number s0 --:mno(n E NAME OF NEW BUSINESS E R,1.2 1 A V C TYPE OF' BUSINESS IS THIS A HOME OCCUPATION? YES NO n Have you been given-9pr AND 9 C7% ADDRESS OF BUSINESS MAP%PARCEL NUMBERS ( - -1 When starting a new business there are several things you must do in order-to be in compliance with the rules and regulations of thV own of- . a Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Ma" St. - [cor►-a of Yar5wu Rd. & Main Street).to make sure you have the appropriate permits and licenses_required to legally opera our usi in this own. u7 o 1. BUILDING COMMISSIONER'S OFFIC ry ca This individual has been informe oLny rmit requirements that pertain to this type of business. "'j M Authorized Sign ture** COMMENTS: `) FOLLOW HOME 2. BOARD OF HE LTH This individual has-bee 'nforrrAdofthepermitreq irements that pertain to this type of business. Auth ized Siffnature** COMMENTS: Qi 3, CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type.of business. Authorized Signature.* COMMENTS: - _ � �- Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: v" k 21 2_ V-\ !' BUSINESS LOCATION: k0l INVENTORY MAILING ADDRESS- TOTAL TOTAL AMOUNT: TELEPHONE NUMBER: Q CONTACT PERSON: . c Lr, Amnave,,_... EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous 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 s Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) 0 Hydraulic fluid (including brake fluid) Refrigerants o 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 0 Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc, Combustible Car wash detergents ® Leather dyes n Car waxes and polishes 0 Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Q 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) Q Floor&furniture strippers Other products not listed which you feel n Metal polishes may be toxic or hazardous (please list): U Laundry soil & stain removers (including bleach) ® V Spot removers &cleaning fluids ` (dry cleaners) Other cleaning solvents tv AA 0 Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS } TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date �O Time: In Out Owner 1!�'`�''y^^y �" Tenant Address P6 ��/ a Address ® 1 Compliance Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities �f 6 l2i 4. Water Supply 3 Cs '_� 5. Hot Water Facilities 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 17.Temporary Housing /�- l qy 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms r Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out Owner , Tenant Address D Address 1QT 0,bl K= 0== V 7- Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities ✓ 3. Bathroom Facilities 4. Water Supply , , 5. Hot Water Facilities 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 f Elements / 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal ✓ 16. Sewage Disposal ✓ 17.Temporary Housing 18. Driveway Width f 19. Number of Tenants Observed l PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehi ed ( x) Number of Persons Allowed (max) Person(s) Interviewed Inspect If Public Building such as Store or Hotel/Motel specify here i TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date a g t I Time: In Out Owner �C .Jf Tenant 'I 4� Address L Address t d 3 Complian Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply _ d 5. Hot Water Facilities Approved, 6. Heating Facilities 7. Lighting and Electrical Facilities 9 9 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 �� "�- 3 �— L-( 17. Temporary Housing a �j 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max)_ Person(s) Interviewed Inspector If Public Buildingsuch as Store or Hotel/Motel specify here P fY r ------------- ` d: rove t? TOWN OF BARNSTABLE Approved: �Rp ppLID ve BOARD OF HEALTH Ceq: �C) I� ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Z. I Z(� I d �G Time: In 0: _S'_ Out 1 U Owner f::,c,o 'C a" s-( Tenant /L Q y f_ S Address f2G�, 2 Z- z-( e., Address 1 y �?V�► �-��✓Z � �,j Compliance Remarks or Regulation# s Ye , NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 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 17.Temporary Housing AVA 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; OA./ U L121 AA,;, Removal of Occupants; Demolition Number of Bedrooms 2 Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector r If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE :; J BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION .Date Z F 2 (� 4 �G Time: In d '� Out 1 U 2 y Owner Sb �u O 'C e2 v S"( Tenant M A /Z y S i Address �G Z Z- 4 Address ( ; y 6?p 1 Compliance Remarks or Regulation# Yes Recommendations NO 2. Kitchen Facilities \"TG1��tJ S� �k. l.fA Le- 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities ul =/ 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 a 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing A,1A 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; �A/ Removal of Occupants; Demolition Number of Bedrooms 2 Number of Vehicles Allowed (max) Number of Persons Allowed (max) �t Person(s) Interviewed\/ �� `1' Q _ Inspector o � - If Public Building such as Store or Hotel/Motel specify here S/4 , f9 (LG OkA �I 2 t <-10 r -- ;Pao DEW TOWN OF BARNSTABLE - =�-JjM'VV0ftkn add BOARD OF HEALTH MLD Cent: ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date i `L I Z z� d�� Time: In l u Out Owner fr, (� T�v S1 Tenant VA.CN too Address �� � 2Z6 Address /® J OU4 kt l- 40 Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities / 4. Water Supply ( ( dam 5. Hot Water Facilities S 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 /% G� 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal R-`v P"t 17. Temporary Housing V/fir 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms ?— Number of Vehicles Allowed (max) 3 Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here i w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS FORM30 C& BOARD , F H CITY/TOWN : W ' ^ f1 D PARTMENT a p ADDRESSIt 2--W GSM SVey`0� fff �' TELEPHONE UU171_._//I` 111 T/jam Address �d Occupan Floor Apartment N No.of Occupan No. of Habitable Rooms_ No.Sleeping Rooms No.dwelling or rooming units o.St ries Name and address of owner Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows.- Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Su ply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) 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 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect..- Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted 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 INSPECTO .( ver) "THIS INSPECTION RE OR SIGNED AN C RTIFIED UNDER TIAE PAINS AND PENALTIES R Y. INSPECTOR TITLE DATE TIME Lool PM A.M. ---THE NEXT SCHEDULED REIMPECTION AA7P.M. L 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 include shall 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 ordinary 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- mon 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. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) 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 or 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. E f • `l � � / (^•� 1 l� l �' f FORM30 C&W HOBBsB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BrIARD OF HEALTH CITY OW W lY o DE TMENT y PaA 1� �j N 1 ;^ ADDRE M sey`0 ({i /� tE -EPH \E Address ®�,�io �✓ I�d1. 4"11 ccupan 1 � `� Floor Apart t No. �f Occu nts No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units N St ries Name and address of owner � Remar Reg. v— YARD Out Bld s.: Fences: Garbage and Rubbish Ay Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central N Equip. Repair TYPE: � Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) 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 , Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas il, Elect.: Stack ues,Ve s,Safeties: Kitchen Facilities Sink Stov Bathing,Toilet Facil. Vent., Plum .,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted 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 It CTI EPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALT J Y " INSPECTOR TITLE 9AN1 �^ /� A.M. DATE TIME co . , t � M A.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 11, 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 include shall 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 ordinary 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- mon 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. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) 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 Ieadbased 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 or 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. ���s� �-��v�13 � �_�� �Q��VGKtT '�-tl(s.,H��f TOWN OF BARNSTABLE LOCATION/Cs/ •—AQ-7 JQ(24 �!�QG� SEWAGE # 7 J VILLAGE_ InW, ASSESSOR'S MAP &LO T36.3'y INSTALLER'S NAME&PHONE NO. /001/m SEPTIC TANK CAPACITY /500 Va LEACHING FACILITY: (type) VQ X /® (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: � � ��i 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 leachi facility) Feet Furnished by � ��/ ��'`� zm �n 177 t " CYTI ` di ; oo Q y No. 7404 �?X_ Fee so THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Migonl *potent Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. %�� " O CaZ�s.�c v— Q� Owner's Name,Address and Tel.No. c-SVVt — (�0 i� V1-e1.1/`Gtl1 Assessor's Ma /Parcel 1 1 p �' 1�5 Z .Cy< �X`Z2LtE3, ��/c.*�.r..� lNt�SS. CTZ6® Installer's`N,ame,Address,and Tel.No. t Designer's Name,Address and Tel.No.\ Type of Building: Dwelling No.of Bedrooms LA Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) S . Nip cA," 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 s and of YSAWa- Signed I DateT�S—�J Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued --------•------------------------------- TOWN OF BARNSTABLE l SEWAGE # LOCATION</lam VILLAGE: ` .. ASSESSOR'S MAPth S T 6' If INSTALLER'S:NAME 8c PHONE'N0. SEPTIC TANK CAPACITY �SOO (size) LEACHING FACILITY: (type)------- NO.OFBEDROOMS y BUILDER%OR":OWNER v / yel -7 PERMrr DATE: Zj q 7 COMPLIANCE DATE: i Separation;Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ( Well and Leaching Facility (If any wells exist Feet private Water Supply on site Or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300,.feet of leachi facility) Furnished 04 .�—..... »ii _.......,�,:;o.,..wr.+v W........y�•..�, _ ..r ..., ! _ . . n— .. +Y.::1 _. r,r ... • __"_ -•=.w.. y.w� y 1. No. Fee .4. THE COMMONWEALTH OF MASSACHUSETTS in Entered computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 2[pprication forlMigoof *pgtem Construction Vermit ' lj A lication for a Permit to Construct( )Repair Upgrade( )Abandon ❑Complete System ❑Individual Components PP P ( ) Pg ( ) P Y P Location Address or Lot No. v\ " V `�"� Owner's Name,Address and Tel.No. Assessor's Map/Parcel /�^ .� \.�. �A)c Z��113, ���c•••�:•S �Nc.gS. UZ�O 0 Installer's Name,Address,and Tel.No. a` Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms sq.ft. Garbage Grinder( ) Other Type of Building.. No. of Persons Showers( ) Cafeteria( ) Other Fixtures " .: Design Flow gallons per day. Calculated daily flow gallon. Plan Date Number of sheets Revision Date t Title f Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) F�=•�e�'^ `�rS�cX�5 . Vw rkbL4� A Date last inspected: r�. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system` in accordance with the provisions of Title_5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued_by-'i d o al&h. Signed Date '7—2`�" y Application Approved by Date 7- a?-97 Application Disapproved for the following reasons y g�� ev Permit No r -,-77 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( ) Abandoned( )by at �0 ,� yPV Irl�iliL^� has been constructed in accordance with the provons f Title 5 and Disposal System Construction Permit No. ' '3�� dated��" ��`� 7 Installer `� �� y ��C`� Designer The issuance of this pe t shal of b n� ed as a guarantee that the system ' 1-func�tion as designed. Date a� -T Inspector — _�J_� __�+ fi � / / � CJ �-------------------------- r— No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 'Wi0pozar 6potem Conelr ction permit Permission is hereby granted tp Construct( Rep � Up grade( 1A�n�n( � , System located at / .p� and as described inlhthe 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 t ' rmit. Dat: z � ; -7 Approve y+ A 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),,'. r I, Z��r L , �,` �, hereby certify that the application for disposal works construction permit signed by me dated , concerning the �t 0-3 y b property located at Tos meets::all of the following criteria: f/• 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 v There is no increase in flow and/or change in use proposed l' There are no variances requested or needed. SIGNED: DATE:. �7 29_2% 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]. _ y ' " f r } n "j r S � ul Lf— s v S _ � S x r f ' - � J r ASSESSORS MAP : /� -- - — ------- --- TEST HOLE LOGS �,,p��� PARCEL: !� I) The installation shall conq,:., Willi"I'ille V an4 d Town of q�4�; �v�Uluurd ui. --- g ,l FLOOD ZONE No � ��/G AG SOIL EVALUATOR: �VI��� I le.ulth Ile ulations. WITNESS: �irJ�IL1- In 12j 2) The installer shall verifythe location of utilities, sewer inverts find septic REFERENCE: , -- l components pricer to installation and selling base elevations. _ f� 1///7Z DATE:---_----------_-_-.-----_.-__- _-- I l 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per (ibol.'I'Ite first PERGOLA I OtJ RATE: : two feet out of the d-box to the leaching shall be level. - — _ --- - --- _Z11 7.._3 �- i ! �(� ( t 4) This plan is not to be utilized for properly line determination nor any other T11 I TH-2 purpose other than the proposed system installation. 5) All septic components must meet ftlle V specifications. 6) Parking shall not be constructed over 1110 septic components. '1 7 The is bounded by property corners and property lines. property 17 8) The property owner shall review design considerations to approve of total ', I b design flow and number of bedrooms lobe considered for design. Iteceipt LOCATION MAPZ of payment for the plan and installation based on the plan shall be deemed �n approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material 04 per Title V abandonment procedures. Those within lite proposed SAS shall >> with contaminated soil and replaced with clean sand per be removed along 1 Title V specs. OU 'l 10)System components to be 10 feet from water line. Sewer lines crossing the sleeved with 4 inch SCl l 40 PVC with ends routed if y�- water line shall be sl g /Z 3Z yd r applicable. The proposed SAS is being installed below the water service 73 line. The line is to be sleeved as aforementioned and maintained in place. 11 If a garbage grinder exists it is to be removed and is the responsibility of the SEPTIC SYSTEM DESIGN g 6 g P Y t _ owner to ensure such. 10 P41 12)The installer is to take caution in excavation around the gas line if such FLOW ESTIMATE 1 exists. k 13)The installer shall verify the location, quantity and elevation of the sewer • F BEDROOMS AT� GAL/DAY/BEDROOM - qV GAL/DAY lines exiting the dwelling;prior to the installation. 2 l) jT'S 14)`this plan is representative only that a system call fit on a property meeting SEPTIC TANK Title V requirements. I ID' %GAL/DAY x 2 DA l S - �GAL I --I 1 USE 1'9bbj GALLON SEPTIC TANK eX15T 4} I I o §6 1L ABSORPTI H S Em— - -- ---_ -.yq UV-� J �L t oi►4E_ Ut"t - o DAVII) c� c� SIDE AREA: z �35's �-�" iZ,$�J' X2X �1 = I�j a MASON y 1 ,� No.toss BOTTOM AREA; N1T th lD , SEPTIC SYSTEM SECTION I'll Viol t /4 op t FrnL. I� V Al GAL AIM � �2, SEPTIC TANK �10*_ U4F"V_ to i _ rb � 7 \ SITE AND SEWAGE I LAI ! 20 LOCAT I Oil : 4 ID J - lb y1;1�W_ I�otq� __ .. PREPARED FOR : M v- SCALE: DAV I D B . MASON,f\5 DATE: Z DBC ENVIRONMENTAL DESIGNS EAST SANDWI CH . MA W DATE HEALTH AGENT ( 508 ) 833- 2177 Z