HomeMy WebLinkAbout0031 SECURITY STREET - Health 31 SECURITY ST., HYANNIS
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` TOWN OF BARNSTABLE
LOCATIONN I SEWAGE #
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VILLAGE CSSESSOR'S MAP &LO ,
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INS't ALLER'S NAME& ONE NO.
SEPTIC TANK CAPACITY �d o
LEACHING FACILITY: (ty ) (size)
NO.OF BEDROOMS
BUILDER OR OWNER I
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 an wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which.you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St, Hyannis.
Take the completed form to the Town Clerk's Office,.1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: iota dr�l� c Fill in please:
r3x� r w} APPLICANT'S YOUR NAME/S: �CJ V
y° ' BUSINESS YOUR HOME ADDRESS: e.cucv
Fi^YYk'F'�P�,b�l1.'Lfl G .5a S4"N
TELEPHONE #_ Home Telephone Number 0'
NAME`OF CORPORATION. .'
NAME=OF NEW BUSINESS z< D!J' e'. t\ ' : TYPE OF BUSINESS Vic
I$THIS,A HOME OC,CUPA IONSS.: NO
ADDRESS OF:BUSINES. �1.� c i S MAP/PARCEL'NUNIBER alarm _ ,1� (Assessing)`
hen starting a new bu mess there are several hings you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COM SSIO R'S DFFI E MUST COMPLY WITH HOME OCCUPATION
This individu ha en o f a p rm UPATI requirements that pertain to this type of business. C ON
RULES AND REGULATIONS. FAILURE TO
Autho ized i nature * J COMPLY MAY RESULT IN F!N �S
MMENT U 1 f cS �lr
i i'a or-, L
d4j�'�d JD ccc
This individual halibee �r�
.f f the permit requirements that pertain to this type of business.
l� r �V i 1 liL � MUST COMPLY WITH ALL
Authorized Signature** HAZARDOUS MATE"KSREGULATIONS:-
COMMENTS:
3. CONSUMER
UM AFFAIRS (LICENSING AUTWORITY ,
This individual has been informed of the licensing requirements that pertain.to this type of business.
Authorized Signature**
COMMENTS:
J
TOWN OF BARNSTABLE Datelo/z l/
TOXIC AND HAZARDOUS MATE 1RIALS REGISTRATION FORM
NAME OF BUSINESS: 1® Ow_f^ Lcl1C�SC� N�
BUSINESS LOCATION: Cd INVENTORY
MAILING ADDRESS: p_C) , �S TOTAL AMOUNT:
TELEPHONE NUMBER: • _1 0-US9
CONTACT PERSON: oulA L_
EMERGENCY CONTACT TELEPHONE NUMBER: �QE_ MSDS ON SITE?
TYPE OF BUSINESS: cJv gcadJ��C
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
s` Automatic transmission fluid �\ Disinfectants
Engine and radiator flushes Road salts Halite
9 (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 ov 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
4 Car waxes and polishes S Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform,formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
1 �s (dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Appl cant's Signatullir Staff's Initials
`, `,..
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 31 SECURITY ST.W. HYANNISPORT (r
Name of Owner H.U.D.
Address of Owner: 330 MAIN ST.HARTFORD CT.06106 ATT.ADELE
Date of Inspection: 8/4/99
Name of Inspector:(Please Print)JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
AUG 1. 0 1999
Company Name: n/a TOWN OFBMV
Mailing Address: n/a NKE
e� HEALTHDEPT
Telephone Number: n/a ` ,t
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 inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The Inpection Is based on criteria defined In Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
_ Needs Further Ev u 'on By the Local Approving Authority performing at the time of the Inspection.My Inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:8/4/99
The System Inspector sha submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10;000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
4
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 31 SECURITY ST.W.HYANNISPORT
Owner: H.U.D.
Date of Inspection:8/4/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I 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:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
Wa One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
Wa 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.
Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
Wit The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
_ obstruction is removed
I
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 31 SECURITY ST.W.HYANNISPORT
Owner: H.U.D.
Date of Inspection:8/4199
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 IN 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 I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nta_(approximation not valid).
3) OTHER
Wa
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 31 SECURITY ST.W.HYANNISPORT
Owner: H.U.D.
Date of Inspection:8/4/99
D. SYSTEM FAILS:
You must 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
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is;less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X 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 ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 31 SECURITY ST.W.HYANNISPORT
Owner: H.U.D.
Date of Inspection:8/4/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X 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:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 31 SECURITY ST.W.HYANNISPORT
Owner: H.U.D.
Date of Inspection:8/4/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-=g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):1
Total DESIGN flow: 330.
Number of current residents:Q
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NQ If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):M
Water meter readings,if available(last two year's usage(gpd): nLa
Sump Pump(yes or no): NQ
Last date of occupancy: 11/1198
COMMERCIAL/INDUSTRIAL
Type of establishment: nta
Design flow: n&gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):�IQ
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:Wa
Last date of occupancy: Wa
OTHER: (Describe)
n&
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Wa
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nLa_ gallons
Reason for pumping: Wa
TYPE OF SYSTEM
XSeptic 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: nta
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM IS APPROXIMATELY 10-15 YEARS OLD.
Sewage odors detected when arriving at the site:(yes or no) NQ
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 SECURITY ST.W.HYANNISPORT
Owner: H.U.D.
Date of Inspection:814/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: L'G_
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: V
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
Wa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
nLa
Dimensions: L 8'6"H 5'7"W 4'10"
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle: 3d
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: n&
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nla
Dimensions: nLa
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle:i3la
Distance from bottom of scum to bottom of outlet tee or baffle nta
Date of last pumping: nLa
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n&
revised 912198 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 SECURITY ST.W.HYANNISPORT
Owner: H.U.D.
Date of Inspection:814/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: nLa
Capacity: nLa gallons
Design flow: nLa gallons/day
Alarm present: NO
Alarm level:ltla_ Alarm in working order:Yes_No_: NO
Date of previous pumping: nLa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nLa
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:n&
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
Wa
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 SECURITY ST.W.HYANNISPORT
Owner: H.U.D.
Date of Inspection:814/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: _nLa
leaching galleries,number: 11La
leaching trenches,number,length: Wa
leaching fields,number,dimensions: nta
overflow cesspool,number: nLa
Alternative system: nM
Name of Technology: _nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION
CESSPOOLS: _
(locate on site plan)
Number and configuration: Wa
Depth-top of liquid to inlet invert: nLa
Depth of solids layer: Wa
Depth of scum layer. nM
Dimensions of cesspool: nLa
Materials of construction: WA
Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:Wa
Depth of solids: iVa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nta
revised 9l2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 SECURITY ST.W.HYANNISPORT
Owner: H.U.D.
Date of Inspection:8/4/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
a AA L
k 1�64
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 SECURITY ST.W.HYANNISPORT
Owner: H.U.D.
Date of Inspection:8/4/99
NRCS Report name: Wa
Soil Type: Wa
Typical depth to groundwater: n/A
USGS Date website visited: Wa
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
XUsed USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
TOWN OF BARNSTABLE '
LOI-ATION� ,e- SEWAGE t 3
VILLAGE v ASSESSOR'S MAP 6z LO F "
INSTALLER'S NAME &PHONE NO. �
SEPTIC TANK CAPACITY P z)c)o
LEACHING FACILITY:(type) (size) d�
NO. OF'BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNEROCLX-e-(4
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: '"' 7 "-q
VARIANCE GRANTED: Yes No
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q � Vai-cle FEB ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applira#iou for UhnVotial Work,i Tomitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair n Individual Sewage Disposal
System at
.----...... ---'--- �_-__��_--
-�------------•-•______________ �4� ----__-__ _--------____----------__--__------__
-'•--_-Lo n-i\ddr ...............or Lot No.
---'---•••----•-•--'.....................
-- Own w address
W
Installer Address
-
UType of Building Size.Lot............................Sq. feet
Dwelling—No. of Bedrooms.•-•,.. __•-•--•----- ---------_-__Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ___________________--_____ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ............................... . .
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No_ ____________________ Width--------:........... Total Length-------------------- Total leaching area....................sq. ft.
3 Seepage Pit No_____________________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) . Dosing tank ( )
1.4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
4. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ------------------------------------------------------------------
- �--- �,.- �.. � ......
--------------------._. .---......._....__..........-------._._._....---------..
0 Description of Soil----------------- ._.
+ -----------------------•--....------------•---------------------------------•-----•-_--•--
----•---•-••---•--•-•---•-.-••-•-------....•---•-••••-
W -----•----•-- ------ -----------------------------------------------------------------------------------------------------------
U Nature f Rep irs o Alter nsnsw n applicable_____________ _ � � L'�S P00 s
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of ComoeNce has been issued by the board of health.
t��.
Signed _ - --- ------ --------------------- -- O 'Z^7-------
D
Application Approved B - 0 ^a7
Date
Application Disapproved for t e following rearons- ----------------------------------------------------------- ------------------------------- ---------- ------- --------
-------------------------------- -------- ------------------------------------ ----- -------------------------------- ---------------------------------------------------------------------- ----- �
1.a-- -�.7
Dare
Permit No. ----- -- -------------------- Issued ...........- D. 9------------------------
Date
T
I/ r7 0,L7Z:)
No.. .=: �Q�C @ �. Fss.. ......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
TOWN OF BARNSTABLE
Appliration for Divi-Vu!3ttl lVnrk.6 C omitrnrttnn ramit
Application is hereby made for a Permit to Construct ( ) or Repair e-`J"'an Individual Sewage Disposal
System at:
.................mow'..f•-----. c� - E� .:. �'
49....
Lo �jon-Address ` - or Lot No.
tea . •---------------
Owne � Address
...-).M. `L S .................. 1 0 5 _;k. �y --•-•-- �it�lc2���(
Installer Address
� S Type of Building Size Lot............................ q. feet
Dwelling—No. of Bedrooms----___ ----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures ------------------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity---------_gallons Length---------------- Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------._- ....... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:4 ----•.... ................................................•-----.
' O Description of Soil-----------------�'----�---- --------- �--�` - - .---------------------._...-----...-•----------•-----...----•-----•-•---......._.....-----
xw- � �+ =....................................................................................
V .....-•--------------•--------•--------....------. -----------------�- ....--------------------------•---.....---------------------•----...-------------------------------------•----•----•--------
UW ----•--------------------- -------------------------------------------------------------------------- -------------------------------- ---
Nature f Rep irs o Alter 'ons— nsw r h n applicable._.._rV_^___.___.._. 5 `"3_.r�._/r_/f._�� `J? �(�/ _ CPSS d� C
a
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Comp la ,ce ha9s`been issued by the board of health.
Signed ...�..±'" c ... �,. ..10 '.Z ^��
....._--...--------------.... ...................... Dace
Application Approved By refloll3owing
:, "`� � ..... -- /..o... ?-.�`�Application Disapproved for t rearont: ........................ .... ----............................ ......................... ................
Date '
Permit No. .......�1...k+... � : ............ ........ Issued .............. d - '7"`�
t t..................._..............................
Dace
____.—_,,... ——
__________________.—_——e_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cfeztifiettte of Tompliance
TH 1S I TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by - �"............ .. ... --1Na.. ... C- �-S.....;.... /v!. * :<x.�
j Insraller
Se �� � :
at -------------------~j ----------- ...... ... '
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ................................................ dated ----------------------.-_-----------------_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............ I. . Inspector,----
---- ✓-'--�--"r-- -- --- --------- --------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� TOWN OF BARNSTABLE
No.....�.. 1..: �� ��' FEE....
�i��u,>�tt1nr� �.un�tr Ilan .ermit
.. ..
Permission is hereby granted--------- ._ w_._ . ._L�-S
to Construct ( ) or Repair ( Individual Sewage Disposal !.ysjetn
at No.............. - - S e C .1- ` - `� ` ''w
-------------------•------- -•---_. ._-------------- ----------- ---5._.._---.-•---
j Street CC,��
as shown on the application for Disposal Works Construction Permit No._Tq.-4�7 Dated......I-_Q_..._ ..)_:71. .
........................ - -�`. ----------------........................................
_.
-..� � Board of Health
DATE............ �•- -----------•--•-•-..._. .__. _........................
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS