HomeMy WebLinkAbout0049 SMITH STREET - Health 49 Smith Street
Hyannis P
A = 288 015
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Date: 5,'1i/ Ul
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS:
BUSINESS LOCATION: LW k-AJ ti r S M� dz 4INVENTORY
MAILING ADDRESS: q!j !S m il-H LT 14 Y,&AJ y I S M 4, a TOTAL AMOUNT:
TELEPHONE NUMBER: SD 9
CONTACT PERSON: ,Q k-<a I.M AIZZ 1 E-
-EMERGENCY CONTACT TELEPHONE NUMBER: RoZ, 29 1 '�� �� MSDS ON SITE?
TYPE OF BUSINESS:
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed/ Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts(Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners .(including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes _
����.
Laundry soil &stain removers '�� o•o
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash UIA
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you .
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this format 200 Main St., Hyannis..
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St.-, Hyannis, MA.02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: c'-Ah Fill in please:
APPLICANT'S YOUR NAME/S � �A
BUSINESS YOUR HOME ADDRESS: el 5 5, M I H e-Tr 14 VAuA11 R o Z 6e-,A
�q 83
tif4�za "fit ; _TELEPHONE # Home Telephone Number
Email Address CL i M
NAME:OF'CORPQRATION.
NAME OF NEW'BUSINESS l'.uEzvo �j�r1�..�LNC� ,��N►oc1�(.►,�E TYPE OF BUSINESS A. 2
IS THIS A HOME OCCUPATIQN?.___2f YES NO
ADDRESS OF BUSINESS K t r 14S k A- n 7=Lnj_MAP/PARCEL NUMBER= (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is*intended to assist you in obtaining the information you may need. You MUST GO T0.200 Main St. —_ (corner of Yarmouth
Rd..& Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. . BUILDING C MISSI NER'S OFFE MUST COMPLY WITH HOME OCCUPATION
This indiv du e n i �PeT �er e uirements that pertain to this type of business._ RULES AND REGULATIONS. FAILURE TO
-
COMPLY hors COMPLY MAY RESULT IN FINES.
MMENT
OntO U 0 ,
l ✓Yl - �m
2. BOARD OF ALTH ir,,t ('c am
This individual has b infor the perms re uirements that pertain to this type of business.
Authorized Signature* MU$t0MPLY'INITH"ALL
COMMENTS: ,HAZARDOUS MATERIALS REGULATIONS'
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Y
Authorized Signature*
COMMENTS:
f
Building Department Services
oFiKe r
Brian Florence,CBO
o*
Building Commissioner .
t RkRNMBLFE r 200 Main Street,Hyannis,MA 02601. .
ut¢c
9 1.639. ��� wvvmtown.barnstable.ma us
Office: 508-862-4038 Fax: 508-790-6230
Approved:
Fee:
Permit#:
HOME OCCUPATION REGISTRATION
Date: LO Z '0 6
Name.- A'.L. A aT i �J phone#: o �B 2-4 q 9 6 3 .
Address: Ql S IN� i S; • Village: u V R A)A) t S
n f
Name of Business: ,r 12� �ti`-�� ,�� l 'M��f�-1 ►.�
Type of Business: � � t Map/L.ot: "; 0 U v V
I1VTE ; It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation
within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the
activity shall not be discernible from outside the.dwelling. there shall be no increase in noise or odor,no visual
aherati.on to the premises which would suggest anything other than a residential use;no increase in traffic above normal
residential volumes;and no increase in air or groundwater pollution.
After registration withthe Building Inspector,a customary home occupation shall be permitted as ofright subject to the
following conditions:
• -The activity is tamed on by the permanent resident of a single fauuly residential dwelling unit,located
within that dwelling unit.
•" Such use occupies no more than 400 square feet of space.
• There are no external alterations to the dwelling which are not customary in residential buildings,and there
is no.outside evidence of such use.
• No traffic will be generated in excess of normal residential volumes.
• The use does not involve the production of offensive noise,vibration,smoke,dust or other particular
matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects.
• There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess ,
ofnormal household quantities.
• Any need for parking generated by such use shall be met on the same lot containing the Customary Home
Occupation,and not within the required front yard.
• There is no exterior storage or display of materials or equipme�it.
• There are no commercial vehicles related to the Customary Home Occupation,other than one van or one
pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to
exceed 4 tires,parked on the same lot containing-the Customary Home Occupation.
• No sign shall be displayed indicating the Customary Home Occupation.
• If the Customary Home Occupation is listed or advertised as a business,the street address shall not be
included.
• No person shall bg employed in the Customary Home Occupation who is not a permanent resident of the
dwelling unit.
I,the under e , ve read and agree with the above restrictions for my home occupation I am'registering.
Applicant �\' Date: D S Z Q
$omeocADc Rev 06&0116
L
Date:4 l3 ff
1
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: CLE- ► ) 1 NyG —Dk i v&s
BUSINESS LOCATION: y-OI d'�► �I'�w1w►vw�S to A INVENTORY
MAILING ADDRESS: AXVKAA, aA OMM&k TOTAL AMOUNT:
TELEPHONE NUMBER: �O2 -c)-cl l—29 5 1
CONTACT PERSON: 1213jSTl W A NFL l
EMERGENCY CONTACT TELEPHONE NUMBER: 50j�-2 4-�5�83 PAOLO MSDS ON SITE?
TYPE OF BUSINESS: -i ICb1 DMT-[AL_ (',1,1;P MtKW,
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform,formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazar ous (please list):
Metal polishes
CA-Laundry soil &stain removers
(including bleach) W Lu k*) CAI,"Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers �j (�LUG ECcCLPEr�v��" 0�1��
Windshield wash V`KU"7(d �
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
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 [lie completed form to the Town Clerk's Office, 1 st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: T 1 h-l7 `
Fill in please:
APPLICANT'S YOUR NAME S ` - �A �)n( I61-F
f y ! f /
BUSINESS YOUR HnME ADDRESS: 1 1 q
TELEPHONE # Home Telephone Number -'/
i
NAME OF CORPORATIONS
NAME OF NEWBUSIN.ESS ,i 1�. 1�/�` T1FPE OF BUSINESS lei F`� I_!>I`�SC
IS THIS AHOMEOCCUPATION� YES NQ_ _
ADDRESS OF BUSINESS MAP' PARCEL NUMBER 2'�' � -.a ,I, � (Assessing)
When starting anew business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE IO MUST COMPLY WITH HOME OCCUPATION
This individual has been informed of any permit requirements that pertain to this type of business. N
RULES AND REGULATIONS. FAILURE TO
Authorized Signature** COMPLY MAY RESULT IN FINES.
COMMENTS:
2. BOARD OF HEALTH
This individual hE n info f th er-m1 quirements that pertain to this type of business.
Authorized ignature*
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
t�
TOWN OF BARNSTABLE �J
LOCAT ON �� 't'� SVUL.1_� SEWAGE #
VILLAGE 14 .4 lyts ASSESSOR'S MAP
INSTALLER'S NAME & PHONE NO. . �4k Ck1. c J 0* S q
SEPTIC TANK CAPACITY 1 {570
n
LEACHING FACILITY:(type) l LL-0 1,7-4140 11 (sue)
NO. OF BEDROOMS . PRIVATE WELL R PUBLIC WATER
BUILDER OR OWNERf{•f-LL.
DATE PERMIT ISSUED: 9 -
DATE COMPLIANCE ISSUED: piJeti
: F
VARIANCE GRANTED: Yes NO
S
_.
c �'-
_dam ® J57�
i
No. ...... 33 Fss... c
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE -~�•
-; Appliratiou for Ditj aril C�a��t r rttnn rrtttif
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
...`t.°...........-........• �.�l IAT .............................................................
Location-Address or Lot No.
s C3puVZ� l�`�'�' '2£�!- ---•---• *4�LAk"� � - 1`I r7 !.dr'I.S.........................
Owner A ress
Installer Address
UType of Building �- Size Lot............................Sq. feet
Dwelling— No. of Bedrooms----------
------------------------------
_--Expansion Attic ( ) Garbage Grinder ( )
a. Other—Type of Building ------------------_----___ No. of persons----_--_-------__-_----.-- Showers ( ) — Cafeteria ( )
QOther 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
W • '
,.� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------- ................
Li, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
--------------------------- -------•----••-•------•-••--•-------•--•--------......--••--
Description of Soil_C. z.........
=------••.....................•----------•----------••-•--•-•-----I...........----
U ........................................................................-.................................................................................................................................
W
VNature of Repairs or Alterations—Answer vXhen applicable. ..... ...T.11-_.._�r' �-g--_ - � 3a?...
} .. -------------------------------------------------------------------------------
Agreement: _ _ I _
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 Compliance has been issued by the board of health. f
r' .../Z__
S
Application,Approved By --- ------------ --- -------------------- ..------------------ ------------------------ ----;-------- --- �. , .
Dace -----
Application Disapproved for the following reasons- ----------------------------------------------------------------------------.............------------------------------ ------
Dace
PermitNo. ..................................--------------------------------- Issued ---------------------------..._--------------------------------
Dare
S
No......
_. ( � Fss..:.. C�
.._......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
` Appliration for Diopoottl 3lork,i Tonotrurtion Frrutit ,
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
a
•---------•----••-----•--- --------------�--------r--V---
----------------------------------------------------------------
Loc atibn-Address ..........................or Lot No.
V . ' �
...................... .................... ?tLyt ^
........................
Owner �t� ( _ ,s / A ress
a ...................................\LL �.+�............-moo----•---`-!:>S^0k �►J :- T��Ttl`.K/
-•---•...............••---•..----••-------••--•.----._........-----
Installer Address
UType of Building Size Lot............................Sq. feet
.-I Dwelling— No. of Bedrooms-----------7—-•------------- ----__-_Expansion Attic ( ) Garbage Grinder ( )
a` Other—T e of Buildiu
4 YP g ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
QOther 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........................................
04 Test Pit No. I________________minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
rs. Test Pit No. 2................minuut per�inc Depth of Test Pit._--___-___________- Depth to ground water..____-_________.____-_.
w _ .........................................................................................................................................
O Description of Soil__Q.'-% ._ _
U
W
U Nature of Repairs or Alterations—Answer when ap licarble. ' �' :1=_�!._._._� ;- _---------!!�s `
SD C� 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 Compliance has been issued by the board of health.
.
Signe .......:..- ------- _... ----_sue_...." _ R/.6 _`3:T
..... ....-..... .................................. .......... /..._ce
Application.Approved By --------------------------- ...........------------------------------------------------ _e
Application.Disapproved for the following reasons: _----------------------_..........._-..-..-..----_------....._---------------------......-------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------"..."...--------------- -.....----------------------------------
Dace
PermitNo- ----------- ---------------------- --------------------------- Issued ---------------------------------......---------------------------
Dace
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Q'Irdtftctt#P of CZumyltttnce
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�)
by -------H-iCI 'I-------51ow Sc—
�)� �Insr.Jler
at ..Z1`..-........ 'l` t� 5 ... ' -------------
has been installed in accordance with the provisions of TI'II.E 5 f T State Environmental Code as de;-cribed in
the application for Disposal Works Construction Permit No. ._.1,53.3... dated . ..5�' . 4�.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE
SYSTEM WY ILL SATISF TORY.
%��
DATE . ./.. ",- - - Inspect ,>�--' �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. �..- 33 TOWN OF BARNSTABLE
No FEE--- 6.........
Diapoottl Worb Tonotrution "Vantit
Permission is hereby granted____KkCfn- ......... �%
to Construct ( ) or Repair (ed an Individual Sewage Disposal System
atNo._!A°k---------S... y --•------ .................... -------------------------------------------------------J-----�p�-..----- ......------.....
Street
as shown'on the application for Disposal Works Construction .Permit No.
_._-__•-______ter___ Dated..--__�-.-__._ ._......._........
--_..... ......--.--------------------••-•----------•-•-•-----••--••--•----
DATE------ ---------------•------------------------------------------•----
Board of Health
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
CERTIFICATION bF.rSKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated s 8 Z concerning the
property located at Li �'� meets all of the
following criteria: ass O/s-
- J
• 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
L
• The observed groundwater table is 14eet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED DATE: '5— ` S
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].
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COMMON �'TH OF Nl
SACHUSETTS S V' ED
EXECUTM OFFICE OF EN TVIRO. �TEMON
DEPARTT�NER R OF BO ENV
1,jA 02108 t6171 292•SSUO JAN 2 0 2000
ONE M COXE
BREWSTER BC�AW,, ,,
OF HEALTH
DAVID B STRUHS
• Corrsrussroner
LLL'•CCl AGE OISPOSAI SYSTEM INSPECT►ON F�M
ARGEO PAUL CE SUpSORFACE SEW PART A
Governor CERTIFICATION
of owe h+O
.1 f
Ad6rass: +,g $M1{�1 .c NyJ.M►is�er>7'Add,c„of Ownc+: Marst O A'rd�t r R
PTop�Y r�n�t� l�
o,.: 113100.nt1 i rcP . of ride 5 1310 C►+tR 15.0001
p,ne of tr spcor purwwd to Section 15.3A0
N"IK of ItsspKt—: ( tee c+n inspect
1 em a DcP approved sy� n ' - Q17�
z6�3
Cp,r,pany t1 an-w:
M,Ang Abyress: _ O - accurate
Tdept"O^e Nude=
and that the inlormaT'on reported below is live.
el this address ° and experience in
the D�^Der function °^
ATEMENT. a disposal system on my
training.
CERTIFIGAT►ON S ersonelly inspected the sew°9 erlo,med based
that 1 have P The inspection W°s p
1 certify of the time of inspection. The system:
and complete as a disposal SYstems.
maintenance of on.site sew°9
Passes thor,tY
Passes. local roving Au
Conditionally the ADD
Needs Further Evaluation 13V
i*4��
Date: •�
I '
DEP peclothm the system
O of
oc.s Sif7^'rwte: on to the AVprovtng Authority IBoe'0 lea era`he rnspeCloj and
the sYslcm owner
Insp� ,nsDKtion rep 1 10.000 gpd o 9 nt toltTt
of this r has a design how o, The original should be se
actor shall submit ° copY stem o I Protection
stem Insp stems a shared SY
this inspection riate regional o 01 the Depart oVnn9 aul ol,ly. °
The Sy It the sY ttict
hOr�tY
completing report to the approp liceble. and the aPD
�Italt submit the he buyer.i1.epD
system owner and copes Beni to t
NOTES ANO COMMENTS
L,tc t ..I 11
SUBSURFACE SEWXGE DISPOSAL SYSU M ti�SPEC�M FORM
PART A
CERTOC,ATIOM( seed)
Addr� S: I�I7e SM 1
Propertll lJJ+1�1i't�1/!a
pate Of ta °n
MSPECTIOM SUMMARY:
a.eck A, B C or v:
ribed in 310 CMR 15.303 exist. Any failure
A_ HM
SYST PASSES'
Of the failure conditions desc
have not found any information which indicates that any
d below.
criteria not evaluated are indicate
CO&DAENTS:
�WMALLY PASSES: aced or repaired. The system,upon
B_ srsTgM c�ofrt '
the Board of Health,will pass.
System components as described in the"Conditional Pass section need to be re
One or more Sy r as approved by explain why not*
completion of the replacement or rcpai, determined".exp( fi-ate of
for with a copy of a Ca"
fir
basis of daterminati owdall
!the system insp�
operator hasp 20 cars prior to the date of the inspection;or
r tank
indicate yes.no,or not determined(Y,M,or Unless
terdc was installed within twenty l 1 Y
The septic tank is metal.unless V`hat thy r or ope n septic tank as
— Con�ance(attached)indicating unsound,shows substantial with anon or ingexfi s ptic n
Pass
inspection if the axistiny septic tank is replaced with a complYi 9
the septic tank,whether a not mete!,is sacked,on ifcthe ,
failure is imrpinent. The system will P
approved by the Board of Health.
ins inspection it(with approval of
h static water level observed in theugs a s�n box is due the Board of
to broken or obstructed pipets)
e backup or breakout or tug box. The system P
Sewage Wed or uneven dsuibrrtion
or due to a broken,se
Health). broken pipets)are replaced
�- obstruction is removed
�— distribution box is levelled a replaced mil.,
-
---"— due to broken or obstructed WPets1• ;hesYst�n -
" The system required pum09w'ote_d+an fourvn+cs a year
clue
approval of the Board of Healthl=
inspection if/
broken.pPe(s1 are replaced
removed
obstruction is remo -
Page 2 0l it
. —I 4 !7 /98
SUBSURFACE SEWAGE D15POS
AL SYSTEM
BtSPECT�N FORM
PART A
CEWt-nRCAT10N t"*--4
Y Address: +9 SM 1(�►
fln►bre Ho /_
OOwn1' 1 �3/ REDU�m BY THE BOARD OF HEALTH- to protect the
stem is fads^9
FJRTHHL EVALUATION C.
evaluation by the Board of Health in order to determine if e s
ire further3 1W THAT T11E SYSTEM
WAconditions exist which d h nvironment. W"310 CMR 15.30
public.health.safety and the t �MWFS W ACCORDANCE THE g�BONM�'
A MACRO yyftIC5L1M11 PpOgCT Tt1E PUBS f¢ALTfi.AND SAFETY AND
11 Sys T1�WLIl PASS UNLESS BOARD OF HEALTtI
lS NOT FUNCTIONING�
50 feet of surface water a salt marsh.
is within vegetated wetland or
� marsh-
Cesspool or priW n 50 Ieet of a bordering
Cesspool or privy is within
DOOMMES THAT THE SYSTEM IS
BLIC WATER SUPPLfER•IF A��Mgl7r -
BOARD OF HEALT1t(AND�LTH.AND SAFETY AND THE
SYSTU M WILL FA L.UNLESS T"E pROTECTs THE PUBLIC ce water supply or
2) NING IN A MANNER SAS is within 100 feet of a s en
urfs
FUN and stem(SAS)and the
stem has a septic tank end SOa absorption system
brc water supply Well.
The system to water supply
tributary to a surface water supply, system andan but 50 feet or more from°
tic tank and soil absorption system and the
SAS is within a Zone o a
The system has a sep and sod absorption
the SAS is within SO feet of a priYi ds Mdicates that the
has a septic t°�and soil absorption system and the SAS cleris and volatileforOarMc comPou^ of to or less
The systemanalysis for coGform and gate nitrogen is eW
The system has°Septic��°well water °nia nitrogen
on from that facility end the presence olapproxima",r►ot void)
private water wPP(Y well is tree from ttiod sed to determine d'stance_�—
.than 5 pPRr• .
31 OTHER
f�ge3ofII
SUBSURFACE SEWAGE MSpOSAL SYSUM RdSPECTfON FARM
PART A
CERIFICATION fc0"6"—_l
Y AGE:CA.a Sm i f�►
page of k ''
15.303. The basis for this
p_ SYSTFIM FA1!S to each of the toUowing= to correct the faiiwe-
'Yes-or'No a following failure conditions exist as described inw at win
n be necessary
Y m t indicate eith ned ibat one or more of should be contacted to determine
have deters The Board of Health shoo -
determination is identified below- ����,r oreiag9�,SA5-or'C°sspod_ l -
. �,,.�f'rn COm{ d°a Q0 M OValruw�" .
-'1ste Ound m surface water s due to an overloaded or dogged SAS or
Yes No Backup of xw°��{ecrMtY'a
Discharge or ponding of effluent to the surface of the 9r
ouget invert due to an overloaded or clogged SAS or cesspool'
cesspool- in the distribuvon box above flow.
Static liquid Level available volume is less than 7/2 day
depth in cesspool is less than 6'below invert e(s1
Liquid NOT due to clogged or obstructed pip
than 4 times in.the last year
Required pumping more r elevation.
_—
Number of times pumped is below the high groundwete
stem,cesspod or envy
onion of the Soil Absorption Sys to a surface water SupplY-
AnY D ace water supply or tributary
_ feet of a surf
Any Portion of a cesspool or Privy is within 100
or privy is-w
itfiin a Zone!of a Drrbhc well"
Any portion of a cesspod vote water supply well*
rivy is within 50 feet of a private wen
with no
of a cesspool or p vale water l watt' for
Any PorUpQ 100 feet but yrsater than 50 feet from a Prr of Well water analysis
P�or privy is less-than been analyzed to be acceptable,attach copy
Any Portion of a case If the well h� and nitrate nitrogen-
acceptable water quality analysis- ndse ammonia truogen _
_ aniccorripou
-cdrform bacteria,volatile org
ILARGESYSTIi3A FAfLS of the following:
cats either yes or No" to each addition to the criteria above:
You must irrd to large systems in and the system is a significant threat to pear'
The following criteria apply or Tester(Large Systeml
The system serves a facility with antb
design flow of 1 of m e o toUovring co"
6lions exist:
health and safety
and the environment because one or more of the
water wpdY
Yes No the system is within 400 feet of a surface drinking
-
_ at�i�ibrrtarirtea�rfeO° A mapped Zone 11 of a public
is..withiA 200 IWPAI or a
the system (head Protection Area-
the system is located in a nitrogen sensitive arse(interim Wellhead
water supply wet accordance
CMR 7 5.304(21. Please consult the local re9'onal
The owner or operator of any such system shall upgrade the system in accordance with 310
office of the peps iment for further information-
p�g�4 of 11
SEwAGE DISPOSAL SYSTEM WSPECTION FORM
SUBSURFACE PARTS
CHECKLIST
r
vroperiY Address: ¢9 Smith
Owner V$/a Jre Me -
Date of kwpectio'^' V-9/ed
Check it the following have been
done'You must indicate either'Yes" or No as to each of the following:
• occupant,or Board of Health- �reeeaal slow
provided by the owner„ aacera�9
Yes _ NO Pumping information wasp MA& -system h-A art of this
t� PILX Fatt°°zt o Weeks stern recently or as P
None of the system eoraPos lw►�'a°n
Y — rates during that period. Large volumes of water have not been introduced into the sY
inspection. are not available with NIA-
fans have been obtained and examined• N°LO if they
As built p signs of sewage back-up-
The facility or dwelling was inspected to(
✓ — or industrial waste go-.The system does not receive non sanitary
The site was inspected for signs of breakout. en located on the site.
_ stem,have be
nests,excluding the Sod Absorption Sy inspected
for condition of baffles
AR system Cog septic-tank was insp
Opened,and the interior of� p depth of scum.
Wholes were uncovered, f depth of 4Vuid,depth of sludge'
The septic tank ma dimensions, site has been determined based on_'
or tees,material of construction, stem on the
The size and location of the Soil Absorption System
Plan at B.O.H. of distance is unacceptab1A
information-For example. approximation
Existing is
at issue,
Wed in the field l- any of the failure criteria related to Part C
Determi Hof
NIA_ ` d o on shad
(75.302(31(b)1
different irnm oWn
Land
The taciGtY owQet Systems.
SubSurtace pispo
Page'of 11
SUBSURFACE SEWAGE DISPOSAL SYS'1EM NSPECMN FORM
PART C
SYSTEM wFORmATfON
pmp�ty Aderd:: ¢9 Sin r tr*+
O.vrrer: Il mAre l/o
Dote of bapection t/3/ 0 FLOW CONDITIONS
R=L
flow' g.p-d-/bedroom. of bedrooms(actual):.
Design •� Number
Number of bedrooms Idesign)
Total DESIGN flow— _
Number of current residents:-L-�� uirad
cinder(Yes or no':-9-0 se uata1nspection,req
Garbage g stem) (Yes or no)-90 it Yes. P
Laundry(separate sY
Laundry system inspected
lIyees or no)
Seasonal use(Yes or not:
Water meter readings.it available(last two Year s usage(gPdl:
Sump Pump(Yes or no):-
Last date of occupancy,__--
COMM0CIAL1lMDUSTRiAL I1
Type of establishment: avd I Baste on 15.2031
Design flow
Basis of design flow
trap present:(Ye$a no'—
Grease _
industrial Waste,Holding Tank present (Yes s no)—
industrial waste tgscharged to the Title 5 system:(Yes or rw1_
water meter readings.H avagable:
Last date of occupancy
.OTHER:(Describe) �
Last date of oceupa^cY
GENERAL INF IO
ORMATN
CORDS and source of information:
PUMtG
SystemWiped as pan of inspection:(yes a nol
g
If Yes.volume pumped'
Reason for pumping=
TYPE OF SYSTiE7M lion system
/Septic tank distribution box/soJ absorp
-J� Single cesspool
Overflow cesspool
privy iirs tction records,if any)
_ Shared system(yes or no) (if YeS•attach d t` operation
P
atipe and maintenance contract
CIA Technology etc.Attach copy of up to date oper
_Copy of DEP Approval
Tight Tank //
as
Other d M(arrration'
t known)ehd souru
APPROXIMATE AGE of all components.date installed li
at the site:(yes Or no)
Sewage odors detected when aniving
Page 6 of t 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM�pEC710N FORM
PARTC
SYSTM INFORMATWU(coat -NA
r
Ploperty Addfeu-. sM!
Oats Of faction. 010d'
6UpDfA1G SEWM-
(Locate on site Plan)
Depth below grade: �fTPVC_other(explain)
Material of construction: CO iron _
Distance from private water supply well or suction line�—
Diameter� joints.venting,evidence of f"kage"I"
Comments:(condition of
SEP-"C TANK:l�
(locate On site Alen) i
! othedercpla"
ncrete_metal Fiberglass polyethylene _
Depth below grade:
Materiel of construction:it-_ (YssMo)
If tank is(netal.fist age— is-age-co" by Certificaje of Comp race
pimensrons:
Sludge depth" bottom of outlet tee of baMe-
pi'tance from top of sludga to
M
Scum thickness:—�-- et tee or baffle:
Distance from top of scum to top of of cadet tee or baffler
Distance from bottomof scum to bottom
Now diment lops were determined: al-integritY-
Comrmer+to Don for,pumping•condition of irJet and outlet tees or-baffles,depth of GNd level in Fetal'
to outlet invert.structur
- (recornmr�� etca
sJdar+re`�:fe7�e.
(IOCAte on site planl
°ther(eWain)
Depth below grade:_
metal—Fiberglass —Polyethylene—
Material of construction= concrete_
Dimensions-
Scum d+ic>kness:_ an►to top of outlet tee or baffle'-
Distance from top of scum
ttom of scum to bottom of cadet tee or baffle•
Distance from bo
Date of last DumP'ng:
cots: of inlet and outlet tees or baffles,depth of fagoid level in relation toCornm outlet invert,structural ir►tegrrtY-
ndation for pumpang•condition
(ram etc-)
evidence of leakage-
page 7 of 11
_ SYSTEM VdSPEC1"FORM
SUBSURFACE SEWAGE MP
OSAL
PARIM d)
SYST WMWAIM(c�prwe
EM
Property Address: /�9 SM ITn
Owner-- om brel/ti
D*te of - ! ection)
4/A,T, must he pumped prior to,or st time of,insp
�T OR IWIDWG TANK- L.�T`�
(locate on site plan)
• —Fiberglass
�Polyethylene—other(ezplain)
Depth below grade: _ ----
Materiel of eonsv"ction: concrete metal_
Dimensions' gallons
CaPaatY'�� gallonsidaY
Design flow:
Alarm Present — order:Yes— No_
Alarm level:—Alarm in vJorking
Oate of previous Pua+W^g'--
ConWW^u=
(condtion of inlet tee,condition of dsrm and float switches,etc.
MTMUTION BOX:
gocate on site plan)
N.
Depth Of RVuid level above outlet invert:��— .
and distribution`Vaal'evidence of solids carryover.evidence of leakage into or out of box.
Comments=
(note if level•
PUMP CtWWBER
(locate on site plan)
in working order.(Yes or No)-
pumps
Alarms in working order(Yes or No)- appurtemnces,etc.l
Corrmments: dition of Pumps
and
er
(note e0.ndition of pumP chub`r,cpn
page 8 of 11
SUBSURFACE SWAGE DISPOSAL SYSYFM WSPECTIM FORIA
PART C
SYSTEM�OMUTWH(can*
a
p,,pe y Addr s:: A,q Si+n 1
owner-- V,,,kred 2
Dew of Irk= V JV I 1
ORpTtiON SYSTFId(SAS)
rred,location may be approximated by non-intrusive methods)
SOIL ABS she;excavation not requ
(locate orr site plan,it Vo
If not located,explain:
Type: number:—
leaching pits•rw number__
leaching chambers,
leaching galleries,number: _ r ,
leeching trenches,number,length:
leaching fields.
rwmber•�rr,ensrons
overflow cesspool.number:,_
Alternative system:
Name of Technology: vegetation,etc.l
C,rnr�ents: hydraulic failur
e,level of ponding.damp soil,condition of
(note condition of soil,signsIDLI
of by 1
CESSPOOLS"
(locate on site an)
Nurnbet and configuration:
Depth-top of liquid to inlet invert'
Depth of solids layer:
Depth of acorn layer:
uw.r,sioiis of cesspool:
µaterials of constxtrctwn=
yt6icetron of Orocnow : �pa
inflow(c Part cgon)
esspoolater must be pumped as
Of
Co^m"nts: of hydraulic failure•level off •
tondrteon of•vegetation.
(note eOr,c"ion of sod,signs
PfWY=�-`f Dimensions
(locate o stte plan)
Materials of constnicti4n:
Depth of solids:_ pon9•condition of vegetation.etc.)
Comments:
drauGc failure,level of
(note condition of soil,signs of by
Page 9 of 11
.. / i /QR
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION MRM
PART C
SYSTEM lIFRMATWN(co brrredl
PtoP,Y A*kess- S M I 1 h
Om ire 112
D#ofr_
OF SEWAGE�PpSAL SYSTEM:erm
S1tET� comes into house(
es to at least two Dermanent reference landmarks or benchmarks
indude ties 100"(locate where public water supply
locate all wells within
rn I t 17 S't
�X4O
V
Page 10 of 11
SYSTM WSPEC'nOM F fM
SUBSURFACE SEWAGE O PART
C
SYSTEM WO<MMATION(oorrtir+1ed)
r Address:PropOfin
¢q Sm�l fi�
Dre,�3`om
NRCS Repoli name
jpTvpe—
Vicel de to groundwater
Data website visited Deep
USGS Wells checked Moderate—�—
Observation Shallow
Groundwater depth:
slope Md C
SITE EXAM surface water
Check Cellar drr
shallow wells
13 Feet
Estimated Depth to Groundwater.__ b ndwater Elevation:
mine Nig Grou
cate an the methods used to deter
please indi
Pions on record
Obtained from Design
_ bserved.Site lAbutting property observation hole,basement smnP et"
O
Datermined from local conditions
Checked with local Board of health
Checked FEMA Maps
Cracked Pumping records
fkad;
{Deal excavatois.installers
Used USGS Data
the High Groundwater Elevation_(M�cbe coarpl
eted)
Describe how YOU estabbshed
FlniSn 4o?dC ���V z0 �jred Cou(j hivc c(:r
woter t �'!�✓, 7 —between 2Pone�s
Page 11 of 11
/ /9R
DATE: 3/.26/02
PROPERTY ADDRESS;-49 Smith Street
----------------------
-- West—Hyannisport _Mass_
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1500 gallon septic tank .
2 . 1-Distribution box . a
3 . 1-Leaching field . 40 ' X12 ' Xl '
Based on my Inspection, I certify the following conditions: RECEIVED
4 . This is a title five septic system . ( 95 Code_ )
5 . The septic system is in proper working order
at the present time . APR 0 2 2002
6 . System was installed 5/19/95
.TOWN OF BARNSTABLE
HEALTH DEPT.
SIGNATURE: _J�.
Name:-J_p _ Macomber _,Tr._-_---
Company: Jose•ph_P_ Macomber_& Son , Inc .
Address: Box 66
Centerville , Ma . 02632-0066
Phone:---508_775_3338----_--
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connectlons
(JOS.E�POH
P.O x 66 Centerville, MA 02632-0066
775.3338 775-6412
Y
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAJRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 49 Smith Street
West Hyannisport ,Mass .
Owner's Name: Philip S .hi 1 ler
Owner's Address: Came
Date of Inspectlon: 3/ 26/02
Name of Inspector: (please print) Joseph P .Macomber Jr .
Company Name: J. P . Macom er & tion nc .
Mailing Address: Box 66
Centerville , Mass . 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system Inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000), The system:
7
-Z/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authoriry
Fails
Inspector's Signature: G r Date: -' Q�
The system inspector shall s bmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authoriry.
Notes and Comments
—*This report only describes conditions at the time of Inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use. `
Title 5 Inspection Form 6/15/2000 page I o
4
Page 2 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 49 Smith Street
West Hyannisport , Mass .
Owner:Hhilin SchilLe—E—
Date of Inspection: 3/2 6/0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
�ystemPasses-'
-
_�� have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The seotig system is in proper working. order at
the present time ,
B. System Conditionally Passes:
_1 One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explain.
10) The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Vd Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
*0 The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:49 Smith Street
West Hyannisport , Mass .
Owner: Philip Schiller.;;.
Date of Inspection:'3 2 6 0 2
C. Further Evaluation is Required by the Board of Health:
AV Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
2'0 Cesspool or privy is within 50 feet of a surface water
A Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
4)6 The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of
surface water supply or tributary to a surface water supply.
-Lb The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
462 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
/LV The system has a septic tank and SAS and the SAS is less than 100 feet but 5A feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. -Other:
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 49 Smith Street
West Hyannisport, Mass .
Owner:Philip Schill_ef--
Date of Inspection: 3/2 6/0 2
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no" to each of the following for all inspections:
Yes No
_ Aackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid,Ievel,�eiution box above outlet invert due to an overloaded or clogged SAS or
cesspoolasquid depth in than 6"below invert or available volume is less than 'h day flow
�equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped Q.
arty portion of the SAS,cesspool or privy is below high ground water elevation.
,_/Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
_ � y portion of a cesspool or privy is within 50 feet of a private water supply well.
�y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
�C7 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes".or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no/
2 the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(I_nterim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
f If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
I "yes" in Section D above the large system has failed.The owner or operator-of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department,
4
Page 5 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 49 Smith Street
West Hyannisport , Mass .
Owner: Philip Schiller
Date of Inspection: 3 2 6 0 2
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
Xere any of the system components pumped out in the previous two weeksZ_- ?
as the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the s stem Y or as recently art of this
Y P inspection ?
_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out ?
Were all system components,*Kluding the SAS, located on site?
t/_ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum ?
Was the facilityowner(and occupants if different from owner)provided with information on the proper
P
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes/no
Existing information. For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b))
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 49 Smith Street
West Hyannisport ,Mass .
Owner: Philip Schiller
Date of Inspection: 3/2 6/0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): :� Number of bedrooms(actual): 3
DESIGN flow based on 310 CIvMR 15.203 (for example: 1 10 gpd x# of bedrooms): r
Number of current residents:MjAkuw
Does residence have a garbage grinder(yes or no):ti±p
Is laundry on a separate sewage system csor no): [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use: (yes or no): ;�D
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): AM d � 11dy'�. r 7A,&a1
Last date of occupancy:
COMM ERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): /4_gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):Ile
Non-sanitary waste discharged to the Title 5 system (yes or no): ,�1g
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): �G '
If yes, volume pumped: 0 gallons-- How was quantity pumped determined? _V4
Reason for pumping: aI/i9
TYP ?OF SYSTEM
?/Septic tank,distribution box, soil absorption system
rP Y
,rb Single cesspool
SOverflow cesspool
Privy
IZ9 Shared system(yes or no)(if yes,attach previous inspection records, if any)
Ze_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
AfD Tight tank .f,Attach a copy of the DEP approval
Other(describe):
AP roxi ate aee of all components, date installed (if known)andu e of'nfo io l,
Were sewage odors detected when arriving at the site(yes or no):_
6
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propert},Address:49 Smith Street
West Hyannisport ,Mass .
Owner: Philip Schiller
Date of Inspection: 3 2 6 0 2
BUILDING SEWER(locate on site plan)
Depth below grade:_ � /
Materials of construction: cast iron !/40 PVC &�) ther(explain): •U�
Distance from private water supply well or suction line: Y';*'
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight No evidence of leakage , The system is
vented through house vents .
SEPTIC TANK: Zlocate on site plan) sSo�Iy'i91�c�='�
��j/
Depth below grade: �
Material of construction: ✓concrete t/zhnetal,!�-J?fibergIass/V_polyethylene
,VJother(explain) �/
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no);'e�(attach a copy of
certificate)
Dimensions: 1A6
Sludge depth:
Distance from top of ludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: /,-40�t
Distance from bottom of scum to bottom of outlet tee or baffler
How were dimensions determined: 149001s!Irhl/
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of-leakage, etc.):
Pump the septic tank every 2-3 . years Inlet & outlet tees are
in place . The tank is structurally sound and shows no evidence
of leakage . Liquid level at the outlet invert is fifty one inches .
GREASE TRABak�Alocate on site plan)
Depth below grade: ,&
Material of construction:.,(//9concreteq�/imetalV�fiberglass re olyethylenel other
(explain):_ /.4
Dimensions: A&If
Scum thickness: wl;91
Distance from top of scum to top of outlet tee or baffle: x�iQ
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present
I
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Add ress:49 Smith Street
West Hvannisport ,Mass :
Owner:Philip Schiller
Date of Inspection: 3/2 6/0 2
TIGHT or HOLDING TANKr1 ,Ie, (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 1,
Material of construction:A14 concrete Wmetal 4o fiberglass polyethylene re/Wother(explain):
Dimensions: A14
Capacity: 1444 gallons
Design Flow: IV4 gallons/day
Alarm present(yes or no): jU
Alarm level:_fL Alarm in working order(yes or no):
Date of last pumping: A�,4
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present .
DISTRIBUTION BOX: !/ if resent must be o ened locate on site Ian
( P P )( plan)
Depth of liquid level above outlet invert: � '
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box has three laterals . N_o evidence of solids cam
over . No evidence of leakage into or out of the box
PUMP CHAMBE /E (locate on site plan.)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Pump chamber is not present
I
8
Page 9 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 49 Smith Street
West Hyannisport ,Mass .
Owner: Philip Schiller
Date of Inspection: 3 26 02
SOIL ABSORPTION SYSTEM(SAS): Zlocate on site plan,excavation not required)
40 'X12 'X1 ' Leachfield . In proper working order at the present
time .
If SAS not located explain why:
Located ; See page 10
Type
leaching pits. number:Q
leaching chambers, number:
Aar
leaching galleries, number: ,�leaching trenches,number, length: �
leaching fields, number, dimensions:
Aj' overflow cesspool, number: C?
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to sandy loam to medium fine sand No signs of
hydraulic failure eb" , ponding Soils are dry Vegetation is
normal . The leaching field is in proper working order at
the present time .
CESSPOOLSeGi&A',(cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration: - Q
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver: A10 _
Dimensions of cesspool: �—
Materials of construction: /f1
Indication of groundwater inflow(yes or no):/�A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not present
PRIVY (locate on site plan)
Materials of construction:
Dimensions: I1L—
Depth of solids: "�4
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Prey ; net—Y T-went
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 49 Smith Street
West yannisport , Massw.
Owoer:Philip Schiller
Date of Inspcctiots: 3 26 02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
6=
gu a
49 6m4k 5
10
II b � TOWN OF BARNSTABLE
LOCATION SEWAGE # - S
VILLAGE H�A4 lycs ASSESSOR'S MAP & LOTAM CJy
INSTALLER'S NAME & PHONE NO. 4k C�kQZCt
i SEPTIC TANK CAPACITY ,
LEACHING FACILITY:(type) El lLAb L,4X'40 X ( (size)
NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER
BUILDER O OWNER U to
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: S 1q i
VARIANCE GRANTED: Yes No
e
I
Page 1 1 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION (continued)
Property Address: 49 Smith Street
West Hyannisport , Mass .
Owner: Philip Schiller
Date of Inspection: 3/2 6/0 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 1,2 If feet
Please indicate(check)all methods used to determine the high ground water elevation:
btained from si lans on record - If checked, date of design plan reviewed:
served site abuttin roe bservation hole within 150 feef�of SA ) o
VAccessed
ecked with local Board of Health-explain:ecked with local excavators, installers ast*h documentation)
USGS database-explain:
You must describe how you established the high ground water elevation:
Used ; Gahrety & Miller Model 12/16/94 Ground water elevations above
sea level .
Used ; - USGS Observation well data ,June 1992
Used ; USGS Annual ranges of ground water Terhniral Rullet; n99-00n-1
,up ul MOM Plate #2
Leaching
•• ''�� L� /il �cet
Groundwater: sect Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is � ,
feet.
1l
`a•.T.1yn/r•RITr-T—ITf.—JIR'PTR TTRtSR!'RTt•.T'�^TRf:1TrlTTT1TTZfTF'!IT'C,'R� .TT9TT�.R"'R—..-. �...
1 TOWN OF Barnstable BOARD OF 119ALTII
•Tn-.••. •••,-_ x_:SUIISHFACR SFWAGF DISPOSAL SYSTEM INSPECTION mm FORM - PART D CERTI FI CATION I
-TYPL OR PRINT CI.EARLI'-
PROPERTY INSPECTED
STREET ADDRESS 49 Smith Street West Hyannisport ,Mass .
ASSESSORS MAP, BLOCK AND PARCEL # 288-015
OWNER' s NAME Philip Schiller
• PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P .Macomber Jr .
COMPANY NAME J . P .Macomber & Son Inc .-e
COMPANY ADDRESS Box 66 Centerville , Mass . 02632
Strvvt Town or City state LIP
COMPANY TELEPHONE (508 ) 775 _ 3338 FAX ( 508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of ' inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check e:
System PASSED
The inspection iihich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con heted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
r1
Inspector Signature D a t,, �✓' a d,o( `
copy of this rt.ification must be provided to the OWNER, the BUYER
Dne
where applicable ) and the BOARD OF HEALTH,
* If the inspection FAILED, the owner or.,.operator shall u
within one year of the date of the inspection, unless alloweddortz;equiredm
otherwise as provided in 3.10 ChIR 16 . 305 ,
partd .doc
Date: 6 . o-2,
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: 6Uk&VU C,L ")IV
BUSINESS LOCATION: 4 q S Yin I -rk- `, / flJtiS Pb2�
I
MAILINGADDRESS: Ste(,, Mail To:
TELEPHONE NUMBER: ` Of �-4�� Board of Health
S U 5/�-+>J ��2T/N� Town of Barnstable
CONTACT PERSON:
P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601
TYPEOFBUSINESS: C-I—fe J IPJ L
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES NO k
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
Floor & furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids 13 9IwI14-
(dry cleaners)
Other cleaning solvents fS V A:S Niv,A
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
TO ALL NEW BUSINESS OWNERS
Fill in please:
APPLICANT'S ILYOUR NAME: j U cS 4-
BUSINESS f" YOUR HOME ADDRESS: AiI'�fd- S rp
14yA--JrJ1-s Pve7r L"A—
TELEPHONE Telephone Number (Home) �;® 0 q
NAME-OF NEW BUSINESS e-0rr-*RyU r-1-f-AIN1Nt. �-No I-wm-f ,ZCFA-Ck_� TYPE OF BUSINESS
IS THIS A HOME'OCCUPATION? t5
ADDRESS OF BUSINESS "1-t q -5PA 14.- 1+ ;4t* aA MAP/PARCEL NUMBER 0
O
When starting a new business there are several things you must do. in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. Once you have obtained the required signatures,
listed below, you may apply for a business certificate at the Town Clerk's Office (Is! floor- Town Hall).
1. GO TO BUIL I ECTOR'S OFFICE (4TH FLOOR TOWN HALL)
This individual as been ' fo'rmed of per i equirements that pertain to this type of business.
Au o,�`zed Signature
COMMENTS:
2. GO TO BOARD OF HEALTH (3RD FLOOR TOWN HALL)
This individual has bee rmed of the permit requirements that pertain to this type of business.
Authorize Signature
COMMENTS:
3. GO TO CONSUMER AFFAIRS (LI ENSING AUTHORITY) = (3RD FLOOR SCHOOL ADMINISTRATION BUILDING)
This individual has bgen i ied of t e lic 19si, requirement�.t at p rtain to this type of business.
Aut prized Signature
COMMENTS:
After obtaining the required signatures you must return to the Town Clerk's Office to obtain your business certificate (cost $20.00
for 4 years.). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L. - it does not give you
permission to operate -you must get that through completion of the processes from the various departments involved.
TOWN OF BARNSTABLE
�Xl�--I- �_SEWAGE # o?��
VILLAGE / / ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY /,'m"e�-
LEACHING FACILITY:(type) rls��U (size)2 woe
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNERtG/��fG
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
'l VARIANCE GRANTED: Yes No
Y
-MV
�]
�� / 4
b
V�
3
�.L� •.
_--.
N � FSS.......?'t�.:.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® O,F�t HEALTH
...7Own............ ....O F .41cYts�4 .............................................................
Appliration for Iligposal Works Tomitrnr#ion amit
Application is hereby made for a Permit to Construct ( ) or Repair (4) an Individual Sewage Disposal
System at:
Shrqa� 144 I
Loc lion-A ress r t No.
...1.221,tRl MAI<��, ..��.�x'-------------•-------•----•-------........... . .52_2_.. i�..��P�_.�xa� riss�lor.'�7.1�1A...............
Owner Addre
� Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' 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 ( )
Percolation Test Results Performed by.......................................................................... Date--------------.........------------....
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 -•••-------••--•--•--•----••---••-••----•------•--•-••--••--.....--•-•----•-••-••-•---•-•----•-••............................................................
0 Description of Soil........................................................................................................................................................................
x
U •-•--•--••••--••---•--•••-•--•--•.....................•--------•----------••-----•-•-•--•-•••-•-•---•----•---•-•--•-•--.....--•-••--•---•-----•••.
w
x 99..---,,-,,------- ---
U Nature of Repairs or Alterations—Answer when applicable._nk�F ._..�Otr o.,c�.ct�.._ �pj�,-_ 4». -
�b_r l lkr .-•--•----------------•-•--•-•---•---......--•-••----------•-......-•-----••--•-•------------------------------
Agreem t:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of A ITI U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued aby the board of health.
Signed_ 13 ......... �3'��......-----
Date
Application Approved BY - --•-••.............:.... Date
Application Disapproved for the following reasons:..............................................................................................................
_
---•-•-••-----------•-•-•••-••--••--•••-••..................••---•-•--•---•-•-----••••---....----•...••--
�r C Date
Permit No..........(l- .........--..a? ,..K,2t----•-------. Issued.......................................................
Date
No.._.A.0.. vx. Fas.........
._.... . .
i THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--•.................. ....................O F....:......:..........:................------...................--.......................
Appliratuan for Dispnsttl Warks Tonstrurtiun rrrntit
Application is hereby made for a Permit to Construct ( ).or Repair (•-4-) an Individual Sewage Disposal
System at:
{
....:...........-_...........-•..:.:.....:...... ..... ........................... _...............--------.................-•---.........----..................................._...
Location-Address _ or Lot No. 1
Owner Address
W l r 1 1 /, r � r,r l f• ,
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QI 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........................
fzq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•••--••--•-••..............•-•--••••-•-----•-•...........--------•----•-••- •..............---.........................................................
-----
ODescription of Soil........................................................................................................................................................................
"W
V ••..............•--••----•--•-•-•--•--•--.....................-•-•--•......_..-•-•--•-------•-----•••••---•-......•--•--•--•••-•...----------- ---.............................._...-•-............
W
x -- - -- ----- - ---•--•••-•--_.....-------- ._...-----------
U Nature of Repairs or Alterations—Answer when applicable..-!--.,..-,.-',..:'�....`' l f • '
kL
f • . ----------------•-• • ••---•-------••••--•-•----•-.--...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
12
Signed.. _�-...........-•--...------. .. ----•--••---.....----•-----•--•--....... ..........................-----
.:. .. .
k- Date
Application Approved By-•••-......---•.� .. .........^ :... .............................
Date
Application Disapproved for the following reasons:..........................................................................................................---
...........-•--•-•---......---•-•-------•-•-•--••--.....-----•---•----------------------------------•----•................_..-•-•---••---...._.....--•-•-•..............-•-•------••-••--••........_..»
5� Date
Permit No..........v -- �- ..---.. Issued..........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
fll _ _
.........!................................OF.......I..........................L
....................................................
C9rrtif utttr of TI-Intpliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( -}
by................. . ..... ...--------•--•---........----•------•-- ---•-••--------.........-----...-----•---•--........................---••--•-•--• »...._
L C �` .�� Installer
{
has been installed in accordance with the provisions of TIT 5 ofl4eeState Sanitary Code as described in the
l�application for Disposal Works Construction Permit o............. ......................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
p- --.....--•--••---•---------------- . Inspector............. ..
DATE................�..�:..�.7....1� S�
r THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.....9...g �7a ............�............................OF.............!............�..E:...................••--••-•-----•--................ F>aa........................
Disposal Works Tottn#rttrtwatt f rrntit
Permission is hereby granted........... ... lr....... ......`.G ..............................................................................»»..
to Construct ( ) or Repair ( ) an Individual Sewa a Disposal System
Street Q
as shown on the application for Disposal Works Construction Permit No...l111 1,\ --•Dated..........................................
................................•... -•.•3��----• -•---------------------•---.-..-------_
� g - Bo
DATE.................... 4....---- =- ....-----•---•-•......-•---
ard of Health
FORM 1255 A. M. SULKIN, INC., BOSTON