The URL can be used to link to this page

Home My WebLink About0009 WINDSHORE DRIVE - Health 9 WINDSHORE DR. ,HYANNIS r, TOWN OF BARNSTABLE °' { LOCATION �;� 9� ( SEWAGE�# �.�� VILLAGE ASSESSOR'S MAP&PARCEL 2 7/ 7 7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ito)� LEACHING FACILITY:(type) (size) ,( NO.OF BEDRO MS � OWNER r V e r'ir PERMIT DATE: COMPLIANCE DATE:,5[(810:" Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 3-qj T-33.9' . 3 -wSIA So. 3 ' . .r dNo. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 1 Application for 30igaal *p!6tem Cougtructiou permit Application for a Permit to Construct( ) Repair(ir Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. �C%h Own e ' ame,Address,and Tel.No. Assessor's Map/Parcel 0 q-1. � ( lv n Installer's Name,Address,and Tel.No. Designer's Name,Address Ind Tel.No. ` m�S Pt _)�`C9 Wf,) ^) Type of Building: Dwelling No.of Bedrooms `j Lot Size ,�(� sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '3SO gpd Design flow provided q©, 3( gpd Plan Date �('1Fj Number of sheets �Revision Date Title 7" Size of Septic Tank 100(o Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) !may l~&t/ n/rkJ �a 4, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe o Date f Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. UZI Date Issued i N ho Fee o. # t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for MigpaaY �bpgtem Congtruction permit Application for a Permit to Construct( ) Repair(Upgrade( ) , Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Q W,,Jcghofe 7Vt Owner' Name,Address,and Tel.No. Assessor's Map/Parcel S I' v Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �vS�Ci S Pt Type of Building: Dwelling No.of Bedrooms Lot Size 1 ,;C(0( sq. ft. Garbage Grinder ( ) t Other Type of Building No.of Persons Showers( ) Cafeteria( ) 0141her Fixtures Design Flow(min.required) ` SO gpd Design flow provided 3 t7. '3(o gpd -,Plan Date Qj�)!ti�('� Number of sheets Revision Date t Title , Size of Septic Tank 100(o Type of S.A.S. " Description of Soil Nature of Repairs or Alterations(Answer when applicable) /N5 t-4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe ,- -, Date 6 ell Application Approved by IMe � Date Application Disapproved by: Date for the following reasons Permit No. Dat.- ir..►aras�ssd ,ram THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( t_ Upgraded ( ) Abandoned( )" `bye �OV c / , Z(C;W tQ I NG at Ct l.O,kA (!%C _V(l 1? Y QA)iJi has been co truc�Jed i o ordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated P -- P _ Installer 5 1b�C9v>J� 1 N( Designer #bedrooms ,. Approved design flow gpd I The issuance of this ermil shall not be construed as a guarantee that the system will Fun,)l)oas designed. /tr Date µ Inspector _J�/(1/ t''l+-< yt v , _.. �_. . . — ————— -- ------ . �►*r.�r�i�+lt�+►�.�..►�rf�.�r.�iia►raiij{�i-rs�-E�.r,Tir �.i��G.ur!}1��.� No. Fee V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS MigogaC 4pgtem Congtruction Permit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at I 6cAl/G/S hod-e 1�/ /& /,-J13 _ and as described in the above Application fbr Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. j Date I ,91Q Approved by Y b t k TRANS.NO.; CITY/TOWN': Q�g �� APPLICANT. Q A tj Pt ADDRESS: el s�re Dr DESIGN FLOW- 3 3.0 gPd REVIEWED BY: DATE: 13 N/A OK. Legal boundaries denoted 310 CMR 15.220(4)(a)] ✓ and lot number noted on plan 310 Street Lot, tax parcel numberp [ P CMR 15.220(4)W] Locus Provided 310 CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for >/ components) 310 CMR 15.220 4 Easements shown .3.10 CMR 15,220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for i/ upgrades]-if not, a variance is required 310 CMR 15.412(4)] Location of impervious surfaces (driveways, parking areas etc.) 310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR ✓, 15.220(4)(c)] Location and dupensions of system components and reserve areas. 310 CMR 15.220(4)(e)] System Calculations 310 CMR 15.220 4 ✓ daily flow ✓ l ' isoptic taiikyca aci (required andprovided) soil absorption system (required andprovided) whether system designed for garbage grinder ✓ North arrow 310 CMR 15.220 4 Existing and ro osed contours P10 CMR 15.220 4 Location and lo' of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220 4 h and i Location and dale of percolation tests (performed at proper elevation?) [310 CMR 15.2200)(01 Percolation test results match loading rate? 310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] s Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Address Sheet 1 of 9 r . N/A OK NO Location of every water supply, public and private, [310 CMR 15.220 4 k ,t-A ✓ A within 400'feet of the proposed,system location in the case ' of surface water supplies and gravel packeO!Oubfic`i6tex,supply ' within 250 feet of the proposed,s stem location in the'case withinI 150,feet of the proposed system location in the case In ...{.. ..r._... .. .; of rivate water wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks fisted in.3,10 CMR 15..21 l and any.. at basins. . located nth n 50.t 310=CMR 5:220 4 :1. Water lines-and other subsurface utilities.located [110`CIVIR 15;2.20 4 m ' waterline cross see 3i0 CNfl� 15 211 l l Profile-of system showing invert elevations of.all.system_ coin ones&-and t ie bottom.of the SAS 310.,CMR15 22, 4 0:' -Sfam' p of desi `er 310 CMR 15.220 i and'310 CMR 15.220 2. Stamp.of Registered Land Surveyor(required if construction activities withinj ft. of lot line; 310.:.CMR 15.220 3 Test Holes adequate(two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2)or as ✓ .approved for an upgrade under LUA at 310 CMR T5.405 l k Test-hole-adequate to demonstrate four feet of suitable material? 310 CMR 15.123 4 Test Holes adequateto,confirm adequate groundwater separation? 310 CMR 15.103 3 Benchmazk within5045'-of.s stem. 310 CMR 15,.220 4 Materials specifications noted?jvarious sections of 310 CNIIt S stem.com on ts.not.> 36" de unless Local U: ade Y p deep ( `C. A roval or.`LUA re uested 310 CMR 15405 1; Address Sheet 2 of 9 i N/A OK NO Size OK? 310 CNM 15.223 1 Inlet tee located'ten inches below flow line 310 CM[R 15.227 6 Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 ✓ CMR 15.227 6 Outlet tee with gas baffle or approved filter 310 CMR 15.227(4)] Note regarding installation on stable compacted-base [310 CNIR c � s ri A "�``'"�" 15.228 1 Separation between inlet and outlet tees(no less than liquid depth) 310 CMR 15.227 2 Inlet/Outlet elevations at least 12" above high groundwater / (except as descri�et310 CMR 15.227(5)) or permitted for upgrades under LUA 310 CMR 15.405 1 k Minimum cover . (Tanks.buried more than 9" must have risers on all openings and on the d-box 310 CMR 15.2228 1 and 310 CMR 15.232 3 Three access coyers (inlet and outlet must be 20" or greater) - ✓ ��s� r middle access at least 8" 7/07 310 CMR 15.228(2)] Access to within 6 of grade - one port for systems<I 000gpd, two forsystem A, 1000 gpd 310 CMR 15.228(2)] All"at-grade covers secured to unauthorized access? [310 C1VIR 15.228(2)] > 10 ft from b!ijft foundation 310 CMR 15.211 1 ✓ Buoyancy calculation Required/Done 310 CMR 15.221(8)] / H-20 Where appropriate? 310 CMR 15.226 3 Setbacks from resources 1310 CMR 15.211 Required when gther than single-family dwelling or flow>1000 d 310 CMR 15.223 1 b First compartment 200% daily flow; Second compartment 100% daily flow 310 CMR.1.5..224 2 .and .3 "U" pipe through or over baffle, outlet of each compartment with as baffle or approved filter 310 CMR 15.224(4)] Address Sheet 3 of 9 N/A OK NO Located`at least ten feet from any water line? [31.0 CMR 15.222 2 Disposal piping it least 18" below water line(when water and sewer cross, see 310 CMR 15.211 .1 1 , Cie anouts r uired/ rovided ? 310 CMR 15.222 8 Thrust blocks s � ed in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable 310 CMR 15.222.6 Proper pitch'on all runs? (.005 within gravity-distributed trenches L/ and beds) [310 CMR 15.251 9 and 310 CMR 15.252(2)(c)] Siphon problem/. leacl field below um chamber Eridca s or vent manifoldspecified? Size and orientafion of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252 2 Materials specififd,'(310 CMR 15.251(5) specifies various pipe types'allowdd) Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a Splash plate or bile tee required on inlet/provided?(when pressure sewer to d-box or-steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if dee er than 9" 3;10 CMR 15.232 3 Inside minimum dimension 12" 3.10 CMR 15.232 2 b Minimum s 310 CMR15.232 3 e Watertight cover if<2000gpd); waterproof manhole if>2000gpd 310 CMR 15 132 3 d ( Capacity(emergency storage above working--design flow)? [310 CNIR,231 2 Proper setbacks 310 CMR 15.211 same as septic tanks Watertight.20-in minium access manhole at least 20"MUST BE TO GRADE 3,10 CMR 15.231 5 Service components accessible(not too deep with piping, disconnects accessible Alarm floats - alarm on circuit separate from pumpsspecified? Exceeds two units must have two pumps operating in lead-lag mode. 310 CMR 15.231 6 and 8 Stable Compacted.Base 310 CMR 15.221 2 . Address Sheet 4 of 9 1 Buo anc calq#g qns needed ?Provided? 310 CMR 15.221(8)] NA '` . - ♦. • Address Sheet 5 of 9 c N/A OK NO WAM Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240 1 Required separation to oundwater? 310 CMR 15.212 ASEegate specified as double washed 310 CMR 15.247 2 System venting requiredlprvvided?-(system under driveway or >36" deep) 310 CMR 15.241 Inspection ports specified and within 3"final grade? [310 CMR 15.240 13 Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) f 310 CMR 15.211(1)[4] and +� Guidance Document Chambers and Gal. in trench configuration supplied with inlet every 20 ft. 310 CMR 15.253 6 Each structure vyith one inspection manhole(if>2000 gpd must be tograde) 310 CMR 15.253 2 Aggregate 1' minimum-4' maximum. 310 CMR 15.253 1 2' sidewall credit maximum 310 CMR 15.253 1 a In bed configuration, inlet eva 40 s S. ft. 1310 CMR 15.253 6 Width 2'minimum 3' maximum 310 CMR 15.251 1 b 100 feet -maximum length 310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater 3x if reserve between trenches 310 CMR 251 1 d Situated along cpntours 310 CMR 15,251(2)] Breakout OK? 10 CMR 15.211 1 4J and Guidance Document minimum 2 distribution lines 310 CMR 15.252 2 a Maximum separation between lines 6' 310 CM RI 5.252 2 d Maximum separation between lines and outside of bed 4' [310 CMR 15.252 e Aggregate depth below discharge pipes 6" minimum, 12" maximum 310 CMR 15.252 2 Separation between beds 10' minimum. 310 CMR 15.252 2 Bottom areauseg in calculations only 310 CMR 15.252(2)(i)] Address Sheet 6 of 9 N/A OK ,.. NO Pressure Dosed System ? Provided pump and piping calculations c� as required 310 CMR 15.220(4)(r)] Pressure dosing Tequired on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A t/ Remedial Use ovals If used in gravelless system-make sure jet-is directed as not to scour soil interface Guidance Document Inspections once per year(systems<2000 gpd) or quarterly >2000 dgood to note on plan 310 CMR 15.254(2)(d)] Construction in f ll -Did the plan specify that the fill shall meet the s ecification of 310 CMR 15.255 3 ? Impervious barrier and/or retaining wall ? Guidance Document / Impervious barrier installation must be supervised by designer 310 CMR 15.25 5 2 Retaining wall'must be designed by Registered Professional En 'veer 310 QLK 15.25 5 2 a Side slope not exceed 3:1 ? 310 CMR 15.25 5 2 Breakout requirements met? [310 CMR 15.252(2)and Guidance Document At least 5 ft. from impervious barrier to edge of SAS (10 f3. recommended J10 CMR 15.255 2 Now Check DEP Approval letters for credits and design conditions c/ If used with pressure dosing do not allow pressure discharge to scour soil interface Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a g6te on the plan regarding the requirement for perpetual maintenanceagreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has lic�submitted a co of a maintenance a eement? Are the variances listed on the plan? [310 CMR 15.220 4 RLS Sta awnecessary on plan if a component is within five feet of property[ine 310 CMR 15.412(4)] ci Address Sheet 7 of 9 New construction or increased flow. [Refer to 310 CIVIRw15.4'1`4 } s a Address Sheet:8 of 9 N/A OK NO. Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply Nell)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.210 - also refer to Policy regarding upgrades of such C, 7 existing systems] Is the system proposed on the same lot as served by private well ? ✓ 310 CMR 15.214 2 Are.the nitrogen loads proposed in compliance? [310 CMR Pumping to septic tank ? 310 CMR 15.229 Shared System lei CMR 15.290] ✓ i i Address Sheet 9.of 9 Town.of Barnstable P# o4?"e Department of Regulatory Services r Public Health Division Hate d auea tbJgr: �s 200'Main Street Hyannis MA 02601 t Date Scheduled V (4 me o AM Fee Pd.400 C. Soil Suitability Assessment for Sewage Disposal Performed By. f i �C_ H�-4� Witnessed By: r�, $ fnJ f LOCATION& GENERAL INFORMATION Location Address Owner's Name `�' W,,,ndskor-t Pam. 1 cu•.� 01.t co-Ati,r Address. q AssessoftMap/Parcel: "L�i f 1 i Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Vs--7 7'7— Land Use rp�y��^JG� ) Slopes(9b) Z' Surface Stones Distances from. Open Water Body l ft Possible Wet Area 7�� ft Drinking Water Well y` it Drainage Way L S� ft Property Line y d �' ft Other ST:CI ::(Street name,dimensions-of lot,exact locations of test holes&perc tests,locate wetlands to proximity to boles) J� I Q� w f �i 064 • rj�1 t N6�S �[U�`r p� . Parent material(geologic) Depth to Bedrock1A Depth to Groundwater Standing Water in Hole: ' Weeping from Pit Foce NIA- Estimated Seasonal High Groundwater � j3zt, DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to soil mottles: In: Depth to weeping from side of obs.hole: in,,r Groundwater Adjustment ft. index Well.# -- Reading Date: Index Well level. Adj,thctor, m4 Adj..drtiundwater Level ,,,e . s PERCOLATION TEST bate, Time Observation Hole# Z Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ II 'rime(9"•6") End Pre-soakYVI yL/LIA-es Rate Min./Inch Z" Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be.conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least:one(1)week prior to beginning. Q:6SEPTICIPERCFORM.DOC DEEROBSERVATION HOLE LOG', Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structurc,Stones;Boulders. Consistency v en o rz FkLL qx---)3'�, C M—c fit, 2.5�j WI DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon . Soil Texture Soil Color Soil Other Surface 6u.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. ld ✓��` SL l z�l-4, o,�2 57S �l� 42=13z C- ill-CSC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil-Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,B.ouldets.' Consistency. Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Flood Insurance Rate Man: Above 500 year boundary No Yes -- Vithin`500yea 'boundary No Yes....._ Within 100 year flood boundary No Yes Depth ofNaturallv Occurrine Pervious Material Does at least four feet:of naturally occurring pervious material exist in all areas observed throughout;,tbe. area proposed for the soil absorption system? 1f not,what is the depth of naturally occurring pervious material? Certification ` tl [�ci � ' I certify that on (date)I have passed the soil evaluator examination approved by-the: Department of Environmental Protection and that the above analysis was performed by me consistent with . the required'training,expertise and experience described in W CMR 15.017.' /l� 0 /Date ' Signature --�--1 rt Q;�.SBP'I'MERCPORM:DOC _ x FORM 30 HAW Ho Ri WARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD �FEALTH CIT /TOWN W o DEPARTMENT , G -------- ADDRESS 1,y 5„0�0 LE PHONE Address _ Occupant__. Floor Apartment 0._ A/& No.of Occupants_ , No.of Habitable Rooms _No.Sleeping Rooms !�)�� No.dwelling or rooming units�h" No Stories _- Name a4address of Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: -tic' scrufZ, Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: ;-7o- O W,0 co BASEMENT Gen.Sanitation: 2 Dampness'. Stairs: Lighting: STRUCTURE INT. Hall,Stairwa : ( 10 ,. Obst'n.: Hall, Floor,Wall,Ceiling: A Hall Lighting: 3 Hall Windows: 1^ 7 oil HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vents ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom A- Pantry Den Living Room Bedroom 1 Bedroom 2 5v Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See?jr) "THIS INSPECTION REPORT SI NED AND CERTIFIED UNDER T E AIN AND PENALTIES OF RJURY." INSPECTOR TITLE t A.M. DATE TIME 3 . d A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G) Failure to provide•adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. 'IORM_ "30 \ I(�t1 k� HOBv:WARREN'M THE COMMONWEALTH OF MASSACHUSETTS j �e - BOARD OF HEALTH 'L CITY/TOW N 4 DEPARTMENT , ADDRESS sey0 'c _ TELEPHONE 1� Address -` _:_ .__ _ Occupant _ -�'� _tic, ` Floor Apartment o. _N� No.of Occupants No. of Habitable Rooms_—_y No.Sleeping Rooms P No.dwelling or rooming units.�_- No.Stories Name and address of OWner____1_F) 1 Remarks Reg. Vio. YARD ..Out Bld s.: Fences: " Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: 410,5 0-0 ;�' "��Z,.�.•C /l�et.�4 .� Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: H(•%V . & ,T 17_I Ilkl - IVCP-0 Roof G` 'w .-✓� i - Gutters, Drains.- Walls: _. 1 �� C. I I Foundation: tad I A Chimney: 1-10-10 C0 BASEMENT Gen.Sanitation: Dam p Hess: Stairs: M Li htin : n A I a , n STRUCTURE INT. Hall,Stairwa :`1W;I,1; -- Obst'n.: _ Hall, Floor,Wall,Ceiling: c A Hall Lighting: _ Hall Windows: ('9 �,�; „� ,., 5" to ,' HEATING Chimneys: I? D + Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: ' H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen ., Bathroom L40.1 � /� /)*^'+•� �� -7,my Pantry "4 Den Living Room Bedroom(1) @ - Bedroom 2 1156 4"t Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY..' INSPECTOR TITLE DATE -Ali rd TIME _ M• A.M. THE NEXT SCHEDULED REINSPECTION + b U A.M. � o 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith,,or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) .Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0) shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. I1t'�r-.+yr'6„y.�ti�.+KF"`°1t,.�.-IIvI'�"� ,/t•'�wrv.°��."r `, �..,�'�R'��"�lr'+v+'M+rY�I�I+.'`'IdK."t�"7'7�rr'�'�•1 rY}Lllu+`t!"`�,r.�s�*+"Tr►•a"�zi°�`4"�,(r'"`'"I".'--� 10 '--THE COMMONWEALTH OF MASSACHUSETTS FORM 30 CI I&W, Ho WAFREM r BOARD OF EALTH &g CITY/TOWN k as: ` DEPARTMENT , ;M ye>•" ADDRESS • (J f TELEPHONE Address �? Occupant Floor _Apartment-No. J✓1'} No. of Occupants 1} No.of Habitable Rooms _ 3 No.Sleeping Rooms Z/��t No.dwelling or rooming units R" No,Stories r Name and address of owner_-___U $rl - - T-sv',� _ Remarks Reg. Vio. YARD- ,.Out Bld s.: Fences: Garbage and Rubbish Containers: - 4. Drainage Infestation Rats or other: 02 STRUCTURE EXT. Steps,Stairs, Porches: `'1(O a Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: H "C' Roof Gutters, Drains: Walls: Foundation: 4-( Chimney: 1''1D— O CV •„t -t , BASEMENT Gen.Sanitation: 7 t< Dampness: Stairs: Li htin : A STRUCTURE INT. Hall,Stairwa :`I f (10)) ,._- Obst n.: Hall, Floor,Wall,Ceiling: , Hall Lighting: 'g fir ' Hall Windows: v rG� T 10 r HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: , PLUMBING: Supply Line: v. ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ' ELECTRICAL Panels, Meters, Cir.: t ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen, Basement Wiring: DWELLING UNIT t Ventil. L to . Outlets Walls Ceils. 'Rind. Doors Floors Locks `^ Kitchen Bathroom L410 rl hft& '}2 Pantry , Den Living Room Bedroom(1) I'7 Bedroom 2 ZCZ Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. . t Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: E ress Dual and Obst'n: General building Posted Locks on Doors: ONE 111 OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH ©R SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY -105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See/Aver) "THIS INSPECTION REPORT S SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES PERJUR"Y. INSPECTOR TITLE_ _ r t.. DATE. (� TIME W _ j) A.M.: THE NEXT SCHEDULED RONSPECTION r P.M. - a.u♦ ±r�l.l ...-..d 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. Date: / 9 TOXIC AND H�ZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: BUSINESS LOCATION: D eMa MAILINGADDRESS: p i Mail To: TELEPHONE NUMBER: Board of Health Town of Barnstable CONTACTPERSON: P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: g- o2 0 Hyannis, MA 02601 TYPEOFBUSINESS: C�OQa� � A�A4 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO 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 other than 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 orcoolantsystems) Drain cleaners Oz 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 end 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 (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS • ' TOWN OF BARNSTABLE LOCATION ss (o�/12 ,5Add-e- ` C SEWAGE # V LAGE /Yc/ .1 /22� ASSESSOR'S MAP & LOa�l"' 2 INSTALLER'S NAME&PHONE NO./W!y Cc-sr ?&tex ry SEPTIC TANK CAPACITY 140 o LEACHING FACILITY:(type) ?f/ (size) NO.OF BEDROOMS �. BUILDER OR OWNER- lW PERMITDA f /��4^ COMPLIANCE DATE: ��' s6" Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching FacilityFeet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet -Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fa 'h Feet Furnished by - r • , �C 1y V y. i, -d No. .7I, MC 1 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYicatiou for Mi5po.5al *p5teut ongtruction permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow s s— gallons per day. Calculated daily flow 33 gallons. Plan Date Number of sheets Revision Date Title Description of Soil �A S►`I°� Nature of Repairs or Alterations(Answer when applicable) et`S'rt-- S-e,07'`_L - - b-LSu Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environm ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been' It � Signed Date Application Approved by Application Disapproved for the ollowing reasons Permit No. Date Issued No. Fee_ THE COMMONWEALTH OF MASSACHUSETTS p. PUBLIC HEALTH DIVISION -TOWN OF-BARNSTABLE., MASSACHUSETTS 01ppYication for Migpooar bpgte ruction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 'Installer's Name,Address,and Tel.No. Designer's Name;Address and Tel.No. �-�J �f F Type of Building: i Dwelling No.of Bedrooms _ Garbage Grinder( ) ! Other Type of Building No.of Persons Showers( ) Cafeteria( ) j Other Fixtures i Design Flow S gallons per day. Calculated daily flow 3:�C7 gallons. Plan Date Number of sheets Revision Date Title Description of Soil 44A.'- `►`I�� "`" Nature of Repairs or Alterations(Answer when applicable) v� G T�/! 4aOt) % ete_ - If,"s i Date last inspected: J Agreement: s r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environm ntal Code and not to place the system in operation until a Ce'rtifi- cate of Compliance has be�sued__ sard of It/ l Signed ";K Date /r., `© � r Application Approved by I. Application Disapproved for the following reasons I p Permit No. l — � _ ""' °� ° Date Issued ' THE COMMONWEALTH OF MASSACHUSETTS ail PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS f certificate of Compliance THIS IS TO CE TIFY,that th- n- ite Sewage Disposal System installed( )or repaired/replaced(V )cn_Zo� by ray,- �C� .-`� for , y �ri.Y f�� n as ... as /,it M4., has been constructed in accordance with the provisions of Title 5 and�the--for Disposal System Construction Permit No. dated Use of this system is condiiao edim compliance with the provisio s t forth below: .. No. O ". _ Fee,f THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS Migpogal *p6tem ConMruction Permit Permission is hereby granted to to construct( )repair{ 4,-)-rn On-site Sewage System located at 3 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: -.I,4r-9l Approved by�,;A-7) • . - wc!YdsYxFi"J"•:2M?JtaR.•w3:r.lA..::`n'IYI,Y:WX`#X:AY'��NIPIn3M1.WeO^y.:+'s�'R.ti.:::'.�',. t t „ CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I reby certify that the application for disposal works construction permit signed by me dated `')-S s17�e .concerning the property located at 9 GyYw J5� = -e meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • Theie are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching Wlity • There is no Increase inflow and/or change In use,proposed • There are no variances requested or needed. SIGN ED:: DATE:. LICENSED SEPTIC S STEM 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]. I s . o Z. 1 �� -�, t S 1►N 6it �F AM t t-Y, ��` B E o R o o n� �--.'�-,_, ._-- _ ' _N � i Wo GARBAGE: 6cummE2 Dealt-Y F%-oW s 110 A 3 - 33o G.P.o I5EPT1� TANK = Z30X150% 2.497;6.P. s :' U51= l000 GAt_. � Dt5Po5At_ P1T y5E tvo0 GAL• '• 5%D%WALL AQEa. qs C4 5 0 S.F x t.o A st G•p OF "TOTA I-. m E51 GH r +2 5 &.P D. 'TOTAL_ DA 11-Y FI-OV4 = 33o G.Po, PS ZCOLATION RATE] VAIN 2MIN ohLE55 W9 97•L 7 J01,117- .1 y WILIIAMJ`cy"6 ►+ oF,l�, 9' /z i C. a ALA'N N r E N au. 19334 Q JON 7V-: Zip \"INA Top oe4aM. ►F �. 400�j (N1�. JQ i . BSo✓G_. , p14T (N� GAS: ' • E vco INY. X 95./ TANK ys.3 IPY /Y/E�. M/ITN 9.SS 9 7 WASNGD 6T[�N 6 •. 2TlFlGD PL07 PLAW .Yoh; PROFILE - L o c A-r 1 o N N�'�.cic1is 3 No� SGA.LE VATS G/1 �83 1 CE R.T1FY THAT ITNE pioPoSE'.D VL<e6t}0Wtj P�-AN REP6tZEN GE 4{EREOl•l GOMPI.`(5 1!JITH"THE S t oEL1N� AND Sr=T5AC.K R.6QuL2EMEN7� ot= 'C1-t� �LDT /G 70WN OP aA2-N.STAgLr-- AND IS 9,=-r .C• 37000 '4 LOCP.TED 'WITNIN TN's t~ op Pt pt DATE I A3 �� C BAxTEzLn Wye: INC. ?411 PLAN 1 S NorT gASFD••G - -.._ REGIS'iE.Q6V'1-ANDSu�YEY�iCS S - OSTEiZ.V1LLE • Mi�'SS. ' I1J'STR.uMENT 5u2vEY -ENE or -T5 Sl�cuL,p - i L.r_i_ •f i I►l G G d o v i i n ►�1-r- n. J _ ri I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s ev TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 9 WINDSHORE DR HYANNIS Owners Name: /cL -fQ i o Owner's Address:. o ,e, Date of Inspection:9/21/06 21 �a Name of Inspector: (please print) Douglas A.Brown �. Company Name: Douglas A.Brown Septic Inspections Mailing Address:P.O Box 145 t� Centerville,MA 02632 ca r— Telephone Number: 508-420-4534 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 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 2ate: 9/21/06 The system inspector shall submit 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, authority. Notes and Comments PIT DRY AT THIS TIME STAIN LINE AT 3 FEET FROM BOTTOM ****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 1 Revised on 10/31/2000 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 WINDSHORE DR HYANNIS Owner's Name: A)e bfo Owner's Address: Date of Inspection: 9/21/06 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 winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: tank could use pumping B. System Conditionally Passes: one or more system components as described in the"Conditional Pase'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 following statements. If"not determined"please explain. 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: 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 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 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 WINDSHORE DR HYANNIS Owner's Name: e k 6 Owner's Address: Date of Inspection: 9/21/06 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 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 I 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 "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: I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 WINDSHORE DR HYANNIS Owner's Name: 1jef ino Owner's Address: Date of Inspection:9/21/06 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 1/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 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 3 10 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 15,006 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 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(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 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'm 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 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 WINDSHORE DR HYANNIS Owner: }-±o Date of Inspection: 9/21/06 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? 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:9 WINDSHORE DR HYANNIS Owner's Name: Owner's Address: Date of Inspection. 9/21/06 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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): NA Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump (yes or no):_ Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): 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): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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 awner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed(if known)and source of information: 1996 mid cape septic const Were sewage odors detected when arriving at the site (yes or no)? NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 WINDSHORE DR HYANNIS Owner's Name: Ae I-o Owner's Address: Date of Inspection: 9/21/06 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ (locate on site plan) Depth below grade: 48" Material of construction: X concrete_metal_fiberglass _polyethylene other(explain) Iftank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 1000 gal Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: 0 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- to deep to measure sludge depth would recommend pumping GREASE TRAP:_(locate on site plan) Depth below grade: Material.of construction:_concrete metal - fiberglass—polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ' Property Address: 9 WINDSHORE DR HYANNIS Owner's Name: ATM Owner's Address: Date of Inspection: 9/21/06 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distrib tion to outlets,equ any evidence of solids carryover,any evidence of leakage into or out of box,etc.): C 00 l N`0 6 - to Oe p�� PUMP CHAMBER: (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.): . Page 9 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 WINDSHORE DR HYANNIS Owner's Name: P g Owner's Address: Date of Inspection: 9/21/06 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: 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.): PIT DRY AT THIS THAE STAIN LINE AT 3 FEET FROM BOTTOM,SOME ROOTS ENTERING PIT CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: HYA�N SSS ORE DR Owner's Name: Owner's Address: Date of Inspection: 9/21/06 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. t 3 - `i`2 B 1 _ 2B OI 3RD 2 3 c� ~ Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 WINDSHORE DR HYANNIS Owner's Name: Owner's Address: Date of Inspection:9/21/06 SITE EXAM Slope: Surface water: Check cellar: Shallow wells Estimated depth to ground water>156" feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: r� O "6 �c.r� OfOM �o�lNtlGc�01� 1Ja y, \� { LOCATION SEWAGE PERMIT NO. VILLAGE Q � A�� INSTALLER'S NAME i ADDRESS 8UILDERf� OR OWNER DATE PERMIT ISSUED 6 - 1 (4 DATE COMPLIANCE ISSUED / �/ �3 1� �� a a`- � r:� �� -�Q �� 1 .,q ,,y, o _.. `I: C.� � � �_ I i1' Nol..IJO _ k Fizs........ ®........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF......�.KV .�. I ...T.l ......V_r. ._........... A.VVliration for M-4paottl Workii Tomitrnrtion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: • Location-Address .....WA .......... ..........v�....................................................... 1, or �,o . ...... ............ . . .......... ............. .....YN. ........................ Owner Address a .................................... ......•...--•-...............••-•--•--•--......--••-•-•-•-................_•--.._.............•-•- Installer Address dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......................................--.--..Expansion Attic (J`j'' Garbage Grinder PC) aOther—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 to ( ) ► 1 Percolation Test Results Performed by--..... ..�AC.�....._.1r...N..'' �--. Date...._-.,3 ........3........ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ RS ---•-•......---•------ ..................................•-•-........- --.......................................................... O Description of Soil......._-._mac....-•�..0C^n........ 5'� o=x ........................................................... V ......................................:a.--\_: -......... ---..........--- ... ...--------.........--•-------------•--•------•- W UNature 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 iITEL 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. .Signe `•-•-•...•...?- `.... .... ._ ... -..-... .. 3 Application Approved S -....--- =- `------------------------- ------------------- -------------------------- Date .... Application Disapp ed f the following reasons:..........................................................................................:................... ...............................•---•-----•-••-••---•...-•••------•--•-••....••--•-----------•---•-----•-'•-•-•-•-••--•......•-••----..._......-•••--..........-••••-......-----•---- •............. Date Permit No......................................................... Issued................................... v, Date ; Fxs.............. ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH_ . ......OF...... ..C • 14 ........... Appliratiou for Diopoottl Workii Tonitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 6-g= ---•---'-,�f �V c......... -`:'�w.........i�. .... � -. ...... ..................•---•------• Location-Address or of Owner Address wc t.. ,.n.s "•--------------------------------- ---------------------------------- ------.....-----...-----------•----..... Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic VT Garbage Grinder aOther—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 to ) `-' Percolation Test Results Performed by __. ....... _ " Date...... -��"�_ ....... a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... . ----- ............. O Description of Soil------.� ' '"........ 0��- n,% ---•-..�!'-- '"5 .N �' }.. `�� ........................................................... x U ---------------------------------------Q........'----------M-�------------------....-ems` `"t' '� W UNature 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 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. Signe �` �J� r. •• •- ......__. Dat Application Approved ) :......_.._ .!`�-�_...__ f .?y---_- ate Application Disapp ed , r the following reasons:............................................................................................................... ........................... •---------••••-----------•........----•--•---•-•--................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD '0F HEALTH ..........................................O F........ .. .r��{-. .-i ........................................ .................. (9rrtif iratr of Tontpliatta TH;5�'IS 1, 10ERTIFY, That the Individual Sewage Disposal System constructed (4,,.Kor Repaired ( ) by..... 42 •---- -- ---•-• _...--•-------...--•--••-•----•------------------•-----------••-------........------------ . Installer at...... -- ....... -----•---------------•-----•--•-.. ----...--•._.... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod as -cribed in the application for Disposal Works Construction Permit No.-r .__-5(2 ,/ dated_(9 .u -- -�'------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTE ILL FUNCTION SATISFACTORY. . DATE.-- J l ...................................... Inspector•... --••• •-�..............••------••........_......._.....•----......---•••••-- �.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................0 F..................................................................................... No. ............ FEE. .............. 7i'spo 1 v Tomitration Vpermit Permission reby granted --•-• ...._....•---.........---•-•-•-•----•----------•••••----------•----•-----•---••...._-••.................•----•---•• to Construct or Repai'E�' " an-h 4 vi al Sewage Disposal System_ at No. �11/ ----------••............ ----• ---- --------- • .._....... -- ---- Street as shown on the application for Disposal Works Construction Permit No.....................115'� __.!_-_. ...__.__........... ----••-------•--•---•-------------------•---- ----- .....---•-•--•-------••----•...--•-- oaTd o DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON I 6lW6LI✓ FAMILY{ — BEOi2ODM �, t.1. ,�' WO GARBAGE Gt Nolz. ISEPT1t TAQK = a3oxl5a% =-4956.P. 0 U51` 1000 GAL. DISPOSAL PIT v6E IvoO E,AL.. 5 1 PSWALL AR.64 = 1�;o S.F �O 9�•98 �' ;_ •9S ,G i.' 15o 6A. x 2.5 = 37 5 G." I BOTTOM AP—EA:.. 1O 5•F._ •� I �f C $.rr. X 1.O G.P I Ili 'TOTAL.. DE51GNs ,+Z5 'TOTAL_ DA 1 LY FLOW = 330 G•PO, PEIZCOI-AT►ou RATE] I IN 2MItV 7�3 . ;. TH• � •SSO� 't �nn : '� N : �� .ry�y• �Pt�H N .- OF WILLI•AM G, �� `�9c ri� 1 ' C. =, ALAN n NYE ,p No.:19334 JON �4 Q1sTeP�`�' •SUK�~ E T�� TOP .FMP Q� i . ,Caa,y £ ,• loco tNV. ',�G'�A ii` • • '13.SGa/C. P14T INS• L I aao K INY. BMX 5'S.9 TAN ;: i P :6 , P!T (NY. f' . JNY• 1 WASI MD 1! �z • ' CERTIFIED PL•oT PL A-WJ 44041477, PROFILE MC— LOCA�TIoN VXAoo/ot 1 8S. 3 No• 5CP.LE e_ R.T I F Y -r vA wr 'f F1 E Pt2oPaSE� F� o wN P L-A N RE P E V-SN C.E• t,{p,a-EoW GOMPL`(5 Y,IITN'THE SIoELIN� A W P SET5.GK 9-G4PU19-etASN'1� oF 'CNE- •�dT �� ; -TOWN OF a4P-.1STAaL�F_— ANv IS PIv'r . o . 37 4- LOGP.TED WITNIW TN,E G OD .a. DAT E ' REG I VT Fc7_r lD%•A►J 0,5 u Q-V rcYoi�S 1 TuIS Pl.�•tJ 1 l�-' NOT gA�jFC — - OSTEi2.VILLE • MASS. (N5-r•R-uN16NT SueVey -rAE OFF5ET5 6W000 NOT DE 'u5E•D-TO DETeF'14\1►4E Lo-r OAL,&: 08/18/2009 11:00 5084775313 ENGINEERING WORKS PAGE 01 'I own of Barnstable Regulatory Services Thomas F.Geller,Director B Public Health Division `� • Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-8624644 S Fax: 508-790-6304 Date: 2V 1 T 6 Sewage Permit#2001 2 Assessor's Map/Parcel 'Z7 1 14—7 Installer&Designer G rtiflcatiM Form ?It"te Designer: v�g��n� $��'"�5Y�i I n C • Installer: �.�•��"`�� Address: n- W. Cf�e.c s+:{l ul Address: P.Q' 7c --moo re �� zG y y ��-•R-eJ f�k\A HMV Q 2-4P32 A .f?fv --i^ , kv\1C. was issued a permit to install a (date) (installer) septic system at `^'d S"\4 e* 'P'' �� g—based on a design drawn by r� ( ess) 7 t MC.E►,%r-f-A f - dated 9 1-3 0� (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required)was inspected and the soils were found satisfactory. r (�` PETER T. er's Signature) McENTCE CIVIL No,35109 (Designer's Signature) (A i$ ) PLEASE TO B STAB PUBLI D N. CO CE L NO BESUM) BOTH F B T THANK.YOU. q:office forms\d�t cam fonndoc LEGEN D ze 0,00 -- 1 .-00 - EXISTING CONTOUR LOCUS eo`ea N / 9.33 x.100.98 EXISTING SPOT GRADE QHW OVERHEAD WIRES R. �F G EXISTING GAS SERVICE ' v �q \' o y Q W EXISTING WATER SERVICE a a �, s �r ' TEST PIT 3 Q cat hbasin Q, 76 EXISTING LEACH PITS �o ®104.48 �13 TO BE PUMPED, FILLED W/ BENCHMARK wo 98,63 SAND & ABANDONED s nyd. o *98. �� EXISTING SEPTIC TANK catchbosin j (TO REMAIN) TOP OF TANK, EL.=96.82 wEsr wuN smEEr �a� ` �• 9,44 INV.(OUT)=95.49t(VERIFY) LOCUS MAP .1 �, NOT TO SCALE PAVED \�, �629 Benchmark Set GENERAL NOTES: O DRIVEWAY b >>g 2) White paint mark conc. ftg. 99.24 / `q� >>' EL.=104.81 Assumed 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL ) BOARD OF HEALTH AND THE DESIGN ENGINEER. V \ 9,46, \ < 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS '•� 100,64 OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE icket fenc ; 10L13 LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: O.12 �� 100,3 kQ -310 CMR 15.405(1)(b): Qj 100.56 de fe 1) A 2' variance to the 3' maximum cover requirement, for 5' of --- - 00 -` ice max. cover. S.A.S. shall be H-20 and vented. `� 5 /Q x 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR /�O G, 0 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE x-100, DESIGN ENGINEER. 100,72 i 0.00 O of �� STEPS UP FROM 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING EXISTING WALKOUT BSMNT FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN x 99 4 --- HOUSE (#58) ENGINEER BEFORE CONSTRUCTION CONTINUES. x T.O.F.=205.48E � _ 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. Go 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 9,62 �`lpp 1 --- THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF i 70' �.` TP-1 10�BJ� ti HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. TP:•2 �� 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. LOT 16 \\�00 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 82 0 i 3 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS ry 12901±S.F` , AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE �9e S8"� e�9 ;T;, - O ,h DIRECTED BY THE APPROVING AUTHORITIES. 7 21 b s ._ 9 ,89 APN 271 147 �� - ,� f 10. iT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY l ^,• / .x 98.90 ^ THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING x 96,9 - 8,45 CONSTRUCTION. x x• -- OF MqS 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 97 30 _J------ I VENT 96.90 ��9p Q � s9C IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND 94- �`` yG PETE T. REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). R �, McENTEE 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE CIVIL "' INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKF ILL. 91.13 . x-�0,52 x 96,38 ( No. 35109 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. { FF ENG - ��--'=---------- 9-:s8' ( y PROPOSED SEPTIC SYSTEM UPGRADE PLAN x'96.00 95.13 94,52, . N 78°34'24" E t 7�6- L 9 WINDSHORE DRIVE, HYANNIS, MA Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 OWNER OF RECORD Engineering, by: SCALE DRAWN JOB. NO. ROUTE 28 OLIVEIRA, SILVANA Engineering Works, Inc. 1"=20' P.T.M. 181-09 %DEUTSCHE BANK NAT'L TRUST CO s" DE E. ST. ANDREW PLACE 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. SANTA ANA, CA 92705 (508) 477-5313 8/13/09 P.T.M. 1 Of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED SEPTIC'TANK " PROPOSED D—BOX PROPOSED S.A.S. FINISH GRADE SHALL NOT BE < EL.94.33 ELEV. TOP INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT' INSTALL INSPECTION PORT OVER END UNIT FOR A DISTANCE OF 15' AROUND THE FOUNDATION OUTLET AND SET TO 6" OF FINISH GRADE PERIMETER OF THE S.A.S. 1 COVER SET TO 6" OF GRADE FINISH GRADE: 99.33 (MAX.) CHARCOAL OR (Existing) � , EXISTING F.G. EL.100.2t F.G. EL.100.Ot CONVENTIONAL VENT MAINTAIN 2% MIN SLOPE OVER LEACHING AREA INSPECTION RISER PIPE L =35' 6 4" SCH 40 PVC 4" SCH 40 PVC LL—L::. 10„ 14" ® S= 1% (MIN.) 6" S 1% (MIN.) 11.5" TO 661 48" LIQUID INVERTLEVEL INV.=95.49tW EXISTING ADD GAS EXISTING - PROPOSED INV.=93.96 1 ` BAFFLE D-BOX 1 ROW OF 14 UNITS AT 4'/UNIT + 2 END CAPS = 56' + 2' = 58' INV.=95.27 INV.=95.10,,' EXISTING 1000 GALLON SEPTIC TANK SOIL ABSORPTION SYSTEM (PROFILE) N.T.& I ESTABLISH VEGETATIVE COVER NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INVERTS PRIOR TO CONSTRUCTION. BAICKFILL WITH CLEAN SAND NATIVE OR PERC SAND) 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE ON A MECHANICALLY COMPACTED SIX BREAKOUT ELEV.= INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). TOP OF UNIT, ELEV.=94.33 3) INSTALL INLET & OUTLET TEES AS REQUIRED. INV. ELEV.=93.96 (3) 5" DIA.OUTLETS 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM ELEV.=93.00 �IIII®II AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL! 15.5" .� f--16" 2- ` 5' MIN. ABOVE BOTTOM OF EX G SUITABLE ` SEPTIC SYSTEM PROFILE T.P. EXCAVATION OR G.W. MATERIA 1 ' �� l NO GROUNDWATER AT EL.=87.8'4 OILS SHALL BE VERIFIED AT TRENCH 15:5" 12° LOCATION PRIOR TO INSTALLATION , TIO 6" ^ 8" N.T.S. SOIL BSOR TIO S C TI H-10 LOADING 2" • \ \\\ EXISTING DESIGN is DESIGN CRITERIA D—BOX . HOUSE (#58) T,O.F.=105.48f NUMBER OF BEDROOMS: 3 BEDROOMS a SOIL TEXTURAL CLASS: CLASS I SOIL LOG DESIGN PERCOLATION RATE: <2 MIN/IN INSPECTIONPORT N DATE: LGUST 12, 2009 (REF 12,668) DAILY FLOW: 330 G.P.D. 00 0? SOIL EVALUATOR: PETER McENTEE PE(SE#1542) DESIGN FLOW: 330 G.P.D. 0 0 "TOP VIEW WITNESS: DONALD DESMARAIS R.S. GARBAGE GRINDER: NO 9 HEALTH AGENT� 2.83 EXISTING SEPTIC TANK: 1000 GAL. CAPACITY �21 ELEv. TP- 1 DEPTH ELEV. TP—2 DEPTH 1 0,. 0„ LEACHING AREA REQUIRED: (330) = 445.9 S.F. TOP VIEW 115" 00, 99.0 98.8 5 „ . M. --L , . /(` FILL FILL 74 9860 11 4 A � I- 34=--I A USE 1 ROW OF 14—QUICK4 HIGH CAPACITY CHAMBER UNITS WITHL (EFFECTIV LE GT a1 VIEW SIDE VIEW , , SANDY LOAM SANDY LOAM ' END IE I ® ® � 10YR 4/2 10YR 4/2 NO STONE FORA 58.0 S.A.S. (TRENCH CONFIGURATION). 11END INVERT 97.5 18" 96.8 24" g g BOTTOM AREA: (GENERAL USE APPROVAL FOR 7.93 SF/LF OF INFILTRATOR) MULTIPORT END CAP SANDY LOAM SANDY LOAM 14 UNITS + 2 END CAPS = 58.0 FT Co % % 1 OYR•5/8 10YR 5/8 58.0' x 7.93 SF LF = 459.94 SF SIDE VIEW NOMINAL CHAMBER SPECIFICATIONS �, ' 95.0 48" ' 95.3 42' / _ h ,�P' C C ., PERC DESIGN FLOW PROVIDED: 0.74 459.94 S.F. = 340.36 G.P.D. .SIZE(W x L x H)............................34" x 48" x 16" ♦ ♦ - ( ) EFFECTIVE LEACHING AREA: _. : � ��(� S4" 1� INVERT ELEVATION....................................... 793 S'SLF , ,oQo�- - M-CSAND , M-C SAND PROPOSED SEPTIC SYSTEM UPGRADE PLAN Q;♦ 2.5Y 6/4 2.5Y 6/4 INFILTRATOR SYSTEMS,INC. -. - _ ; , .. ,-:. .a 9 WINDSHORE DRIVE, HYANNIS, MA 31 6 BUISNESS PARK ROAD —f P.O. BOX 768 ' ' �I ' P.O. Box 145 Centerville MA 02632 sEcrloN VIEW OLD SAYBROOK, CT o6475 Prepared for: D. A. Brown, Inc., , PH. (800) 221-4436. FAX(860) 577-7100 WWW.INFILTRATORSYSTEMS.COM - ' - ' , Engineering by: SCALE DRAWN JOB. N0. QUICK 4 HIGH CAPACITY INFILTRATOR CHAMBER ` ' 88.0 13 87.8 132" Engineering Works, Inc. NTS P.T.M. 181-09 INFILTRATOR CHAMBERS PERC RATE <2 MI ("C" HORIZON) 9 9 NO ,GROUNDWATER ENCOUNTERED 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. S.A.S. LAYOUT (508) 477-5313 8/13/09 P.T.M. 2 of 2