HomeMy WebLinkAbout0042 SUDBURY LANE - Health -42 Sudbury Lane
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Hyannis
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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,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
t ci DA7l`E:QV2/i Its Fill in please:
APPLICANT'S YOUR NAME/S: U112 CRCtR/+ pC RGU60-3-EOM 3 ✓►IDL
BUSINESS YOUR HOME ADDRESS:1f oL 5VIJBUR4 ,i_1r\ N`IAy\w►S TV1.A , c2Gv1
py Sh8:36�.o�D
TELEPHONE # Home Telephone Number
NAME,17FCORPORAfiION Ql�TlCC A,5sicn !w►DS� apt C
.NAME'OF NEW`BUSINESS: TYPE OF BU5jNEss AVl 6ScA?i"G.
IS THIS.A HOMEbCCUPA�IpN? YES NO .
n
ADDRESS OIF,BUSIIVES S�� v2 MAP%PARCEL NUMBER U�1 :2�.I. - [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 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
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH
This individual has been n he permit requirements that pertain to this type of business.
MUST ITV lV � F;AZAR OUS MAOTERIIALSWTH REG L
Authorized Signature* ATIOni.q
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:
I�
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l7i�II �3
TOWN OF BARNSTABLE —1
Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: TtQzL- 0 cLASS(cAL 1Av)4scg PInG.
BUSINESS LOCATION: 441 AV%MS INVENTORY
MAILING ADDRESS: 4,2 SuobuQ�-j LA %44A1nwiS TOTAL AMOUNT.
TELEPHONE NUMBER: p% i 36�. ®SOS
CONTACT PERSON: Tvy►ioR
EMERGENCY CONTACT TELEPHONE NUMBER: 'Tov%%'oR 50g- 3G OSOl MSDS ON SITE?
TYPE OF BUSINESS: i-AADCeAPiyAG
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 SAG 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
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash °
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
Hazardous Materials Inventory Sheet Checklist
L---Date
�ghysical Street Address-Check database to ensure it exists
Working Phone Number
�tual Amounts—(i.e.gas being used to fuel machines,thinner to
an brushes all count as hazardous materials)
Storage Information—location of storage,how long is storage for?
If none,note that.
Di'
i osal Information—where and who? If none,note that.
Applicant Signature—understand what is listed and noted.
Staff Initial—any questions,know who to ask. .
Vehicle Washing/Rinsing?—provide a vehicle washing policy and
explain it—note that it was given.
Attach the Business Certificate with your sign-off and comments.
"The Inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them
a
TOWN OF BARNSTABLE Date:/Q /21 / ak
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS:Te fZ/Ate-/ 4'
BUSINESS LOCATION: �Z> C I/v 4�vrz ,/ /_ W i-Z M,/V/vi r INVENTORY
MAILING ADDRESS: 1'/Irn _F TOTAL AMOUNT:
TELEPHONE NUMBER:�a'8� �
CONTACT PERSON: ,(� ry s ro/y
EMERGENCY CONTACT TELEPHONE NUMBER: -� ��Z_� L / MSDS ON SITE?
TYPE OF BUSINESS: /1i9 %/y
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: 0 f Last shipment of hazardous.waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
.10 oPaintsvarnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
_ F__NEW V USED Any other products with "poison" labels
-Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor &furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers �(FF xz' GSJ n d 4 d
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents 1
k
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates COST $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the 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, I" FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get
the Business Certificate that is required by law.
DATE:ZQ2 X 11�2 69
Fill in please: f '
- x APPLICANT'S YOUR NAME: 2-1
BUSINESS YOUR HOME ADDRESS: <
TELEPHONE # Home Telephone Number 5 rp
NAME OF NEW BUSINESS TYPE OF BUSK ESS• - 7rr� jl
IS THIS A HOME OCCUPATION? :-yYES NO \�
Have you been given approval from the building division? YES NO
ADDRESS OF BUSINESS �"" /,�/� //r �✓ ^� /y h. MAP/PARCEL NUMBER
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 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 COMMISS ER' OFFICE MUST COMPLY WITH HOME OCCUPATION
This individual ha sf en f rmec_f',a p rmi req irem is that pe ain to this type of business. RULES AND REGULATIONS. FAILURE TO
COMPLY MAY RESULT IN FINES.
orized Signatur
COMMENT
Au A-
2. BOARD OF HEALTH
This individual ha
s een infor d of hePermit re uire_ments that pertain to this ty
pe of business.
Authorized gnature** ���'�=��
COMMENTS: 1WU COMPLYWTHAL {
S REGU
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
�~ Authorized Signature**
COMMENTS:
x .
c'
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
Z
DEPARTM OF ENVIRONMENTAL PROTECTION
R�CE��Ep
r a jl jN 3 0 2004 [AAP
�M see
TOWN OF E�rtNal,�eLE
PARCEL
HEATH DEPT. TITLES
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner's Name: LUCY BRAMANTI
Owner's Address: 6 DOVERDRIVE BURLINGTON,MA 01803
Date of Inspection: 6/16/04
P
Name of Inspector: (please print) JOHN GRACI,INC. F I LOT
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title (310 CMR 15.000). The system:
X Passes
_ Conditionall P ses
_ Needs Furt valuation by the Local Approving Authority
Fails
Inspector's Signature: Date: 6/16/04
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspect' n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****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 ImnPntinn Fnrm 6/1 5/?OhO 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner: LUCY BRAMANTI
Date of Inspection: 6/16/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a 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: n/a
n/a 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: n/a
n/a 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: n/a
1
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner: LUCY BRAMANTI
Date of Inspection: 6/16/04
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless h y the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well".Method used to determine distance n/a
"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:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner: LUCY BRAMANTI
Date of Inspection: 6/16/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to 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 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pwnped n1a.
X Any portion of the SAS, cesspool or privy is below high ground water elevation.
X Any portion of 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 1 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. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large 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
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
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
d
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner: LUCY BRAMANTI
Date of Inspection: 6/16/04
Check if the following have been done. You must indicate"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 Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period`?
�I
X Have large volumes of water been introduced to the system recently or as part of this inspection?
_ X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components; excluding the SAS, located on site?
X _ 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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ 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)]
I
I
S
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner: LUCY BRAMANTI
Date of Inspection: 6/16/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2 ,
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):220
Number of current residents: 0
Does residence have a garbage grinder(yes or no):NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): YES
Water meter readings, if available(last 2 years usage(gpd))-J& 3_ `.ZOO Ck�,
Sump pump(yes or no): NO
Last date of occupancy: 6/13/04
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1982 PER OWENR
Were sewage odors detected when arriving at the site(yes or no): NO
F
Page 7 of 11
OFFICIAL INS
PECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION(continued)
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner: LUCY BRAMANTI
Date of Inspection: 6/16/04
BUILDING SEWER(locate on site plan)
Depth below grade: 8"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade:2"
Material of construction:Xconcrete_metal_fiberglass—Polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate)
Dimensions: L 8' 6"H 5' 7" W 4' 1011"
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner: LUCY BRAMANTI
Date of Inspection: 6/16/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches, etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
I
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
D-BOX IS STRUCTURALLY SOUND.
I
PUMP CHAMBER: _(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.):
n/a
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner: LUCY BRAMANTI
Date of Inspection: 6/16/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF
FAILURE. STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN 4" OF LIQUID IN IT.BOTTOM IS
AT
8 FT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
A
Page 10 of 1 I
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO
N FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner: LUCY BRAMANTI
Date of Inspection: 6/16/04
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.
VV
0
1040 �
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Page 11 of 11
a
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 SUDBURY LANE HYANNIS,MA 02601
Owner: LUCY BRAMANTI
Date of Inspection: 6/16/04
SITE EXAM
_Slope
_Surface water
_Check cellar
_Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design,plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
r
L0CAT_ 1� SEWAGE PERMIT NO.
VILLAGE
INS? A LLj R'S NAME i ADDRESS
Jo
�e
IDUIL ®ER 09- OWNER
f�'Iq'Yi<o P
DATE PERMIT ASS UED
DATE C 0 M P L I A N C E ISSUED ,f �y
O
N
00
Fes$...... ...............
THE COMMONWEALTH OF MASSACHUSETTS
��a ,L,� BOAR® OF HEALTH
2^\ .T ..
own.. .............OF...........��"ns'a�Z. �.e...---.. ........--------
Applir�ation for Biipnaal Workii Cnontaurtiun ramit
Application is hereby made for a Permit to Construct (R) or Repair ( ) an Individual Sewage Disposal
System at
�. ..........Lat_#... ... r... ... .t s--.. x3rannia, N1�4.....--•-••--•---.....r•------•-•---•--. .
Location-Address or Lot No.
-Capricorn, Realty.,.T..rg
t........................ - --7.6.5...FRlmouth..Raad. H s.......-•------- .
Steve Lebel Owner Address
a .................................•----------•---•--------•------...---•--------••--•-----•-------• --------------------------•----------•----•-•-------------....--•-------------•-----.....---------
Installer Address s
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...........3............................•..Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building X=Ch........... No. of persons............................ Showers ( 2) — Cafeteria ( )
Other fixtures ---------•-------
W Design Flow____..__.___s ..........................gallons per person p�er�day. Total d�ily flow..............33Q__.__.:_..._.__.._.._.gallons.
WSeptic Tank—Liquid capacit}iQQO..gallons Length :..6....._ Width.l.A 1.0.. Diameter................ Depth...
x Disposal Trench--No. .................... Width..................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....1.............. Diameter....6.'.:..._..... Depth below inlet....6.!............ Total leaching area.....266....sq. ft.
Z Other Distribution box ( ) Dosing tank
`-' Percolation Test Results Performed by.....Eldr'edge...Engineer .......... Date.41...25—al'.............
,4 Test Pit No. 1<-_:2s 9--minutes per inch Depth of Test Pit__12!------- Depth to ground water-none...e=ounte�—`
(i Test Pit No. 2...NIA----minutes per inch Depth of Test Pit__N/.&......... Depth to ground water__ .__ a........... e
:.-------•--------------
O -Description of Soil................
-a.$... -29.........loam..&...topsoil
-------------
------------------------•-----------------------------••----•-------
x 2 ...... .Q.'......
madium..yellaW...sand------------...
......
--....................
-----
w .........................._..___._......_....1. .'--------1.2'.._..med.._.__vyhite___sanditraced...o-f..gravel./rya---water---at 12'
VNature of Repairs or Alterations—Answer when applicable...____.....................................................................................:...
----------------------------------•-•-----------•-----......-----------------•---------•------------------------------...-------------------------------•----..........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE '5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued y the board of health.
Signed = ........•-- ,[--- e
//nn1l,1
WI Application Approved By_.�:... �. -•- %%��j ..�_. .1/ �'te
Date
Application Disapproved for the following reasons----------------------------------------•--------------------------------------------------------------.....:._._
...........................•-•---•-----------------------------------.---------•--...•-•-•------------•-----------------------------------------------------=----------------------..................
Date
PermitNo........................................................ Issued-.......................................................
Date
r
V t
No......807... ... Fss......... ... `.
�x
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............Town.................OF...........Harns-table.............................................
AVVIirativu for Bi-spoiial Murky Tonotrurtiun amit
Application is hereby made for a Permit to Construct (g) or Repair ( ) an Individual Sewage Disposal'
System,at:
fi ff
� v ......r.... ........ 123'�,8
Location.Address
.........Qa.prioorn..malty_...T.ruat........................ ....... b5...Fga suth...Road,...H-yannis...............,
Owner Address
Steve T,ebej. .......
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling-No. of Bedrooms........._3...............................Expansion Attic ( ) Garbage Grinder ( )
PLI Other—Type of Building ramh............ No. of persons............................ Showers ( 2) — Cafeteria ( )
Otherfixtures ------------------------ ---••----....---------------------------------------------------•-------..........---............_.._....
Design Flow..........................................gallons per erson per day. Total daily flow-__----__--_.__
g 55 g P P P Y Y 0 gallons.
R:., Septic Tank—Liquid'capacitAAOO..gallons Length_8.:,.6_..... W idth..4.__ G"..Diameter................ Depth..5:-g11
_-._..
Disposal Trench—No.....................Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....i______________ Diameter....6!:_.__._._. Depth below inlet...6_!_............ Total leaching area.....266....sq. ft.
Z Other Distribution box ( ) Dosing tank
� Percolation Test Results Performed by.-_--Eldredge-__En -ineer i Date...11_2 1...............
g 5-� ea
0.4 Test Pit No. 1<..2.0.•minutes per inch Depth of Test Pit..:_1,2!........ Depth to ground water.r}p. ..............---N/A----minutes .......... water----
W
0 Description of Soil---------=------W--------21.........lei M. ..&...t 6011...............................................................................
U
....................................................2 10-------m --
edium-'--ys14W--sand-----------------------------------------------___-___------_--______-
x ----------------- = = 14=.......1-2......--med.--white---sand/traee-d--af--grave:/rw-wter---at 12'
U Nature of Repairs or Alterations—Answer when applicable...........................................................................................:...
•------------------------------------------•--•-•--•----•--•------------------------........---•--------•------------------------------•---------------•---------.............----...--••------•---•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance'with
the provisions of'TILT L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in 1
operation until,a Certificate of Compliance has been issuedd by the board of health. /
Signed.Z_ �IZ
C ! l
Date
Application Approved By. �,• ------------------------------------- , ., i
Application Disapproved f or'the following reasons---------------------•----------•-----------------------------•-----------------•--------------.........----_..._
iE ..............•--•-....•--------------------•--------------..........._......----------•----------------'----------------------- ......................................................................
Date
PermitNo......................................................... Issued....................................................... i
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................Tow ..............OF............Barnstable.........................................
�rrt.if irat a of TontpliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X) or Repaired ( )
bY---------Steve,-Lebel---------- -------------=-•-------------------------------------------------------------------------------------------------•--------•---------•-------
Installer
at------ - ae=-' �•Lr`�:. _°C..�.�-.._._.__... - --------------•-- � - - ---•---_---- i
I7pt / fii1Y3¢3 1
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.�2,r_��6............... dat d_--.-___.__._._....:_-_____.___................
THE ISSUANCq OF THIS CERTIFICATE SHALL NOT BE CONSTRU A GUARANTEE THAT THE
SYSTEM WIL -FU CTION SATISFACTORY.
DATE...... ` -------• ...................................... Inspector.......... .... -- ............................................................
THE COMMONWEALTH OF MASSACHUSETTS 3
BOARD OF HEALTH l
a
Town.......................OF...-.......Barnstable......----------
N�..... .....-......... FEES-�r�..............
Disposal Vorkg TyAono#rndion antic
Permission is hereby granted-------- 8ve ; �3@g - -----------•--•------------------------•--........----....-•--•---.............
to Construct ) or Repair ( ) an Individual Sewage Disposal System
at No.-=------Lb�..�._.��z_ �.c.✓J�r:r..�.� ��,....e.---....---.---------------------------------
Street �n _S.,_._
as shown on the application for Disposal Works Construction Permit No..................... Dated.`�%�:.. s__. .._.:_._......
E'_ ....................... ar of Health
DATE
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
4
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a\ �. A r 4 �a, B./� �YP.4�ysION Q ��
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LEGEND ,a , CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION: OxO: �P - ° --. �
EXISTING CONTOUR -- 0 - - �� :�, G_D,T 3 Y -5tdP13 r2y L.� E
FINISHED SPOT ELEVATION ( oo ALB Fj�j i �r,q A/M�
FINISHED CONTOUR ® RSE. " I
0.10951 Q
APPROVED = BOARD of aIE LTH 901- A 'tASL MIAs +
DATE AGENT SCALE, f 3 DATE �-
"LDREDGE �ENGINEERING CQ IN ENT q"r�A i CERTIFY THAT T.HE PROPOSED L1 r.___�__�
EGISTERE .REGISTERE. JOB NO.,. BUILDING SHOWN ON THIS PLAN
CIVIL LAND ,. CONFORMS TO THE ZONING LAWS
ENGINEER EYOOR DR-BY'. A, OF BARNSTA LE , ASS.
712 MAIN STREET CM:,BY;l'
HYANNIS, MASS; , u T..LO.F A E EG. LAND SURVEYOR
SHEE
/VOTE /F EITNER THE SEPTIC 7-A v/< OR
20 iT MIN.
!EACH/ivG P/T ARE MORE TiHA "J /2"BE L0,PV
/a P7! MIJV.. 'rRAGEj A 24'Q/AME74 CO/YCR.ETE COMER
SWA-LL B.E B•POUG.HT TO GRAoE.�.-;N EiYTRA
4�PYC P/PE
CONCRdTt 'HEAVY CA ST .S/rA I-L 13E USED
_ M/N. P/TCt� .
P .
ELcf/: 9T C•OYERS /B"PFip FT /FIN'DR/vEJOe%4Y
2 MiN. CO/VCRE TE
CO ✓ER CL EAiV .SANO
&AG
L/4pt/l0 LEVEL
!'AS `LAYER
lRCN PIPE U'1T0. o • o •o Of l/8 -3/6` is
;4 'd► MIN.P/TUV GAL.. D/ST. e I • . . . . a r • s �4 WASHFO 570/YE
SEJ�T/C TANK . t • . . r r • . , i
- - B�X o' • i 8 • • • too I•• 4
i 314
. - EF/�ECT/VE . •
• r • • pppr • • • • • o W.45RFP ST40NE
o • o. t • • • • • •• ► y , p ,PREG45 T SEE.,PAGE'
�g-x / ==� Q i•� r • • • • • • • ► • •o P/7 OR EQU/V.
!Ni/GRT CLE✓.4T/oNs. At PLC-v, 6
/NYERT:AT 40I114,01V6 _FT. Vol
JNL ET .SE'PT/G' T.4/VK 91.O .FT. i x t #3 - F7: O/Al►�.. C SEE TABULATION)
44174eT SEPTIC 7*i1NK 93•� FT, �.
INLET O/STRlB!/T/ON BOX 3,:3 /=T GROVNO W,47, .TABLE
SECT/O/V O/w
OdTLETD/STR/B/JT/ON BOX A7.
INLET cgA.t//IIvG vI z %S Fr. SEINAGE O/SPASA t SYSTEM '
P �
LrEACNINGs "7A8UL�4TlO
SCALE 01MEN510At A FT
DES/6X CRITERIA. c
NUMBER OF BEDROOMS 3 D/HENS/ON C�_FT. C A'
GARQAGED/SPO.SAL UNIT NoN� �< 50/1- LOG'
TOTAL E3T/MA'r'ED FLOH/ •3 3 O G.4L,1A0A SO l L TEST Ak!': SOIL TEST*2 SO/L TEST
h&MBER OF• LEACHING PiTS_� ELG•K 9�s ELE•K ,DATE OX SO/L. TEST
SIDE L,CACH/NG PER 0/7- /FTC sca -7...
7 — � Z J RESULTS"WITNESSED dY J RS r0
t9oT7OM LE>AICN/NG PER P/T so. PT. PERCOLA7°/OJv AATE,II/ G� IJ/V,/INCH E
TOTAL LEACH/NG •AREA 6 SQ FT LOA/yt ,G� gWhCO4A rlON RA7"E 2 %h`� M/N INGK
RESERVELS4CMIN6AREA u0 6 SQ FT To/:;�Sta L; Z1 C7
�aaa� u Z�..
r��tltOF 1N,�ss9y �� •.,F M .•'.
41
c ti ORSE
a A No. 10951�d ELOREDGE ENGJ/V6ER/XG CO /NG. l
FQI £��Q` Ago �GrST� `a�� L, �[, Z. 7/2 !NA/N ST. , A,ygc/N/S. A -T-T.
`• NO SU SrONjk%- a�_ NO 6,T0&INO Yi44TY•R ArNC0Uiv7ERE4oFi2A NCC7
Q GROUND WATER AT.EL€1/. - JOB ND: F"/ 2vS SHEFT_�OF 2..
TOWN OF BARNSTABLE
LOCATION L42 �Wll = SEWAGE #
V i.LAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY D
D WILID41
LEACHING FACILITY: (type) LPACP UIL (size) (P L L�
NO.OF BEDROOMS Z
BUILDER OR OWNER
PERMPTDATE: 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 etlands exist
within 300 feet of leaching facility) 1l A 0 Feet
Furnished by lX f c
TS�
Ry
� I
` I�