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HomeMy WebLinkAbout0035 WINTER STREET - Health 35 Winter St., Hyannis A= H.R.S. -- _ �r f Y YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates COST $30.00 for 4 (WHICH YOU MUST DO BY M.G.L. - it does not give you permission to operate). years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1'' F1. You must first obtain the necessary signatures on this form the Business Certificate that is required by law. 3b7 Main St., Hyannis, MA 02601(Town Hall) and get Fill in' please: APPLICANT'S ; . DATE: l BUSINESS YOUR NAME: S v YOUR HOME ADDRESS: TELEPHONE # S �—vV d `c NAME OF NEW BUSINESS Home Telephone Number: IS THIS A HOME OCCUPATION? TYPE OF BUSINESS 9 Z Have you been given a --YES NO g approval from the building division? YES ADDRESS OF BUSINESS NO When starting AP/PARCEL NUMBER a new business there are several thins Cf—Z-G ' ��� _ZZ Barnstable. This form is intended to assist you in obtaining the information g you must in in order to u . compliance with the rules and re u.lati Yarmouth Rd: & Main Street) to make sure you have the a g ons of the Town of you may need. You MUST GO TO 200 Main St. — flown. appropriate permits and licenses,required to legally o (corner of g Y Aerate yCE our business in this 1. BUILDING COMMISSIONER'S This individual has been irifoOrmeld of an - y permit requirements that pertain to this type of business. COMMENTS: Authorized Signature** 2. BOARD OF HEALTH This individual has b en , roe oe permit requirements that pertain to this type ype of business. COMMENTS: Authorized Signature** 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been.informed of the licensing requirements that pertain tot th is type of business. COMMENTS:: Authorized Signature** YOU WISH TO OPEN A BUSINESS? For Your Information: ' Business � "` . .Cd-tifi Cates cos t $30:00 for 4 years. A Business Certificate Cate ONLY REGISTERS which YOUR NAME in you must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office 1' FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and 200 Main Street Offices at the Licensing counter. Fill in please: APPLICANT'S YOUR NAME: EttuG� v S BUSINESS YOUR HOME ADDRESS a 4 G P PCs TELEPHONE # Home Telephone. Number: J NAME OF NEW BUSINESS 1 OVItm o 67� Ch"-- P,t4Z. TYPE OF BUSINESS / f f l�Gr x- IS THIS A HOME OCCUPATION? YES NO Have you been given approval from the building ?g division? YES N ADDRESS OF BUSINESS ' �� azee MAP/PARCEL NUMBER �c1 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 er permits and licenses operate your business in this town. P enses required to legally 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 s been f rred o t�i� p rmit requirements that pertain to this type of business. Authorize .Signature** �.. "-aMMENTS: Rnnl to YVUITHq - :: , LATIONS 3. CONSUMER AFFAIRS (LICENSING AUTHO TY) This`-individual h en inf ed of th ice irig.r quirements that pertain to this type of business. Authorized Signature** COMMENTS: LEI Environmental Services Inc. NA V 401-S Second Street Everett, MA 02149 SERVICES Phone:(617) 389-8880 Fax: (617) 389-9502 `t www.lviservices.com boston@lviservices.com NOTIFICATION OF ASBESTOS ABATEMENT ATTENTION: Hyannis Health Department P.O. Box 534 Hyannis, MA 02601 LVI Environmental Services Inc. will be conducting an asbestos abatement project at the following location. Please note the site and dates listed below. Do not hesitate to contact us at(617)389-8880 with any questions on schedule adjustments, as the start and end dates are subject to changes. BUILDING LOCATION: Washington Mutual Bank Receptacle Site 35 Winter Street. Suite 103 Hyannis, MA START DATE: 4/27/04 END DATE: 4/27/04 Asbestos signs will be clearly posted in all areas where work is being conducted. Please take the necessary precautions in the event you are required to enter the building during an emergency. If you have further questions with respect to this project,please do not hesitate to contact our office at any time at(617)389-8880. Thank you very much for your attention regarding this matter. ' Very truly yours, LVI Environmental Services Inc. Sarah Marcone Projects Coordinator f Rl ' Commonwealth of Massachusetts ■ 1100004028 Asbestos Notification Form AN F-001 ---_Decal Number -------_ - Affix Asbestos Notification Decal Here --_--_---------------------------- Important:When filling out A. Asbestos Abatement Description ' forms on the computer,use 1. a. Is this facility fee exempt-city,town,district, municipal housing authority, owner-occupied only the tab key residence of four units or less?❑Yes ❑✓ No to move your cursor-do not b. Provide blanket decal number if applicable: Blanket Decal Number use the return key. 2. Facility Location: Washington Mutual Bank Receptacle Site 35 Winter Street, Suite 103 aa.Name of Facility b.Street Address Barnstable 02601 eS c.City/Town d.State e.Zip Code f.Telephone Number INSTRUCTIONS 3. Worksite Location: 1.All sections of this Electrical Receptacle Site form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room completed in order to comply with 4. Is the facility occupied? ❑✓ Yes ❑No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division of Occupational LVI ENVIRONMENTAL SERVICES INC 401-S SECOND STREET Safety(DOS) a.Name b.Address notification requirements of 453 EVERETT —� 02149 1 1617-389-8880 CMR 6.12 c.Cityrrown d.Zip Code e.Telephone Number AC000097 g.Contract Type: ❑✓ Written ❑Verbal f.DOS License Number Christy Kingsbury, CB Richard Ellis IProperty Manager h.Facility Contact Person i.Contact Person's Title 6 TREVOR J HOWARD I JAS032886 a.Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS Certification Number Envirosafe AA000131 7' a.Name of Project Monitor b.Project Monitor DOS Certification Number Yee Consulting Group I IAA000145 $' a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number =0 9 04/27/2004 04/27/2004 a.Project Start Date mm/dd/ b.End Date mm/dd/ 0 7am-3pm I IN/A N c.Work hours Mon-Fri. d.Work hours Sat-Sun. �o 10. a.What type of project is this? sO ❑Demolition R1 Renovation — ❑Repair ❑Other, please specify: b.Describe 11. a. Check abatement procedures: ❑✓ Glove bag ❑ Encapsulation —o ❑ Enclosure ❑Disposal only =L ❑Cleanup ❑Other,specify: -- ❑Full containment b.Describe _—z —Q 12. Is the job being conducted: 0 Indoors? ❑Outdoors? .. ■ an oc•10/02 Asbestos Notification Form•Page 1 of 3■ I Commonwealth of Massachusetts ■ 100004028 —� Asbestos Notification Form ANF-001 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or enca sulated: 0 1 a.Total pipes or ducts linear ft otal other surfaces square c.Boiler,breaching,duct,tank [� d.Insulating cement surface coatings Lin.ft. Sq.ft. Lin.ft. Sq.ft. e.Corrugated or layered paper II I� f.Trowel/Sprayer coatings pipe insulation Lin.ft. Sq.ft. Lin.ft. Sq.ft. i g.Spray-on fireproofing h.Transite board,wall board Lin.ft. Sq.ft. Lin.ft. Sq.ft. i.Cloths,woven fabrics j.Other,please specify: F 16 Lin.ft. S ft. Lin.ft. S .ft. k.Thermal,solid core pipe the/sheetroc insulation Lin.ft. Sq.ft I.Specify 14. Describe the decontamination system(s)to be used: Two-chambered decontamination facility with wash station 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM will be wet(hand to bag).ACM will be properly labeled,packaged and transported. 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP Official b.Title c.Date(mm/dd/yyyy)of Authorization d.DEP Waiver# N/A e.Name of DOS Official f.DOS OfficialTitle g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver# —0 17. Do prevailing wage rates as per M.G.L.c. 149,§26,27 or 27A—F apply to this project? Yes No B. Facility Description =o 1. Current or prior use of facility: bank receptacle site �o 2. Is the facility owner-occupied residential with 4 units or less? ❑Yes No Washington Mutual clo CB Richard Ellis 1111 Third Avenue, Floor 28 3' a.Facility Owner Name b.Address —o Seattle,WA 198101 1 1206-554-5126 o c.City/Town d.Zip Code e.Telephone Number area code and extension U. 4 Chrlsty Kingsbury,CB Richard Ellis 1111 Third Avenue, Floor 28 a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address — Z Seattle,WA I 98101 1 1206-554-5126 9�Q c.City/Town d.Zip Code e.Telephone Number(area code and extension) ■ anf001ap.doc•10/02 Asbestos Notification Form•Pa a 2� of 3 -s Commonwealth of Massachusetts 100004028 Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont.) N/A 5' a.Name of General Contractor b.Address c.City/Town d.Zi Code ee.Tee Number area code and extension f.Contractor's Worker's Comp.Insurer q.Policy Number hExp.Date mm/dd/ 6. What is the size of this facility? a.Square Feet b.Number of floors q C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): LVI Environmental Services Inc. 401-S Second Street Note:Transfer a.Name of Transporter b.Address Stations must lEverett 102149 1 1(617)389-8880 comply with the c.City/Town d.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 Waste Management NEET 1203 Pickering Street, PO Box 144 a.Name of Transporter b.Address Portland, CT 1 06480 (800)272-3867 c.City/Town d.Zip Code e.Telephone Number 3. N/A a.Refuse Transfer Station and Owner b.Address c.Cityrrown d.Zip Code e.Tele hone Number 4. ITURNIKEY LANDFILL(WASTE MGT. NH) a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name 71 97 ROCHESTER NECK ROAD I IROCHESTER c.Final Dis osal Site Address _ d.City/Town NH 103839 (603)332-2386 e.State f.Zip Code g.Telephone Number O D. Certification Q_N The undersigned hereby states,under the ISarah Marcone �o penalties of perjury,that he/she has read the a.Name b.Authorized Signature o Commonwealth of Massachusetts regulations 113rojects Coordinator � --1 for the Removal,Containment or c.Position/Title d.Date mm/dd/ Encapsulation of Asbestos,453 CMR 6.00 and (617)389-8880 LVI �� 310 CMR 7.15,and that the information contained in this notification is true and correct e.Tele hone Number f.Re resentin to the best of his/her knowledge and belief. 401-S Second Street p a.Address tL Everett 02149 -, h.City/Town i.Zip Code �Q • anf001ap.doc•10/02 Asbestos Notification Form•Page 3 of 3 Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: Ali R d S a BUSINESS LOCATION: '3 5- W/ n. 7?iZ S 1-7— - MAILINGADDRESS: Mail To: TELEPHONE NUMBER: Board of HealthTown of Barnstable CONTACT PERSON: E�� ���P� d e 9 �Co /S�P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINE ri4, W t g 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 or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Paint brush cleaners Any other products with "poison" labels (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 C Q A s tJ USA o (dry cleaners) i7T ' o y PA , to c ._ Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: 141 R e BUSINESS LOCATION: S W i w 7 MAI1_I1\19ADDRESS: Mail To: TELEPHONE NUMBER: Board of Health q; / Town of Barnstable CONTACT PERSON: h c/S-; P.O. Box 534 ,.. EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINEg,�..,�� 4 /A c,►2 j2� oLr�c /yr Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO �C 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 or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers 4 �4 Paints, varnishes, stains, dyes PCB's $ Lacquer thinners , Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint& varnish removers, deglossers Any other productswith "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 C Q AS I (> ytl USA a (dry cleaners) 17 v S �('o y Ll f2 ,r,► c Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Massachusetts Fire Incident Report Hyannis Fire Department Date of Time Of Arrival Time In FDID Incident No. Exposure #. Incident Day of week Call Time Service 01922 EA230160 E::�= 2/10//2, 31 Monday z] Ki�il IEE i4 Address �_ f Zip Census Tract 3 5 Winter Street j f Hyannis I F4 0 Type of Situation Found Type of Action Ty <en Mutual Aid 41 Spill/leak W/o Ignition 41 3 Investigaation Only Fixed Property Use Ignition Factor "uncovered Parking Area."__]Jj5j 1 00 No Fire Found Occupant Name Occupant Telephone Professional Suites 508-771 -8404 Owner Name Owner Address Owner Telephone North Winter Street Realty 35 Winter Street 508-771 -8404 Method Of Alarm Shift No Of Alarms # of Personnel Responded Hazardous 1 Telephone 1 1 © Materials Engines Tankers Aerial Other Vehicles Present 000 000 000 001 No Fire Service Other Injuries Injuries 0 0 0 Fatalities 0 0 0 Injuries 0 0 0 Fatalities 0 0 0 Rescues 0 0 0 Mobile Property Use Is Car Stolen Insurance Company 0 Mobile Property Make Year Model Color License Number VIN 0 0 0 Complex Area Of Origin Estimated Loss Equipment Involved In Ignition Form Of Heat Of Ignition 0 0 I If Equipment Was Involved In Ignition Material Ignited Year Make Model Equipment Serial Number 0 Method of Extinguishment Level Of Fire Origin Number Of Stories 0 Construction Type Detector Performance Sprinkler Performance Extent Of Damage Flame I J= Smoke Material Generating Most Smoke Type Of Material Generating Most Smoke IF— Avenue Of Smoke Travel Weather Conditions Commanding Officer 0 D.I.aalx.......................................same......................, I Lt Knowlton Report By 1Lt Knowlton HYANNIS FIRE DEPARTMENT - INCIDENT REPORT COMMENT PAGE Incident No. A230160 Address 35 WINTER STREET Date of Report 2/10/2003 Commanding Officer JU Knowlton Report By JU Knowlton I received a call from Phil McBain, Cyn Environmental (781-341-1777 ext. 133), reporting that his company was en route to three (3) locations in Hyannis where earlier today there was a hydraulic fluid spill. He stated that a dump truck from Waste Management Inc., 378 Route 130 Sandwich, Ma. (508-790-3100), was picking up dumpsters and sustained a hydraulic leak that was not discovered until the trucks' last stop. He gave me the following three addresses; 35 Winter Street, 16 North Street, and 26 Main Street. He stated that Waste Management Inc. reported the spill around 0730 hours and they sent people out to clean up the product. He also reported that the spill is estimated at 25 gallons and his company has a 1/2 to 3/4 hour ETA. (RTN 4-17628). Mr. McBain advised me that his contact at Waste Management Inc. was James Clament (508-962-9680), and at the Massachusetts DEP was Tyson Rose (508-946-2850). I responded in 803 to 35 Winter Street, Braunstein & Cohen Attorney's, and arrived to find an area around the dumpster "cleaned up". It appeared that someone had applied speedy-dry to the area and swept it up. There was one storm drain adjacent to the spill area and there was evidence of some product in it. There was no need for our response to this location so I secured and headed to 16 North Street. I could not find 16 North Street nor 26 Main Street. I called Waste Management Inc. via cell phone and found that the two addresses were incorrect. The corrected addresses were 60 North Street and 426 Main Street. I then headed to 426 Main Street - see A230162. and for 60 North Street see A230161. Richard A. Knowlton, Lieutenant LO CAT ION SEWAGE PERMIT NO. VILLAGE INST LLER'S NAME �i ADDRESS B U I L D E R OR OWNER � DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i4 IZ7 o `k- 'fLA 10 � . v,, c II N THE COMMONWEALTH OF MASSACHUSETTS BOARD OF - EA TH .......... 0 F.. .... ]c............................... Appliration for Bispvaal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct or Repair (X an Individual Sewage Disposal System at: ...................... ................................................................................................... L ation ddhs 4.* or Lot No. o s cn.......................... . .......................................................... OwnernC Addmss........................................... ...�;T Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. gorns__ _F_xpansion Attic Garbage Grinder ---------------- 04 Other—Type of Building .............................No. of persons..............7------------- Showers Cafeteria 114 Other fixtures ............................................................................................................................... t4 .................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width.............._. Diameter________--_----- Depth................ Disposal Trench—No..................... Width................._.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet..........._........ Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) 0­1 Percolation Test Results Performed by-----------------------*---------------------------------"---------------* Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.._....._____.__........ Test Pit No. 2................minutes per inch Depth of Test Pit._............__._.. Depth to ground water.__......_...__....._... ................................. ......................................................... * - ------- I - - ------------ ------------ 0 Description of Soil............. . ....... .. ..................................... ................ . ... .. ... .... ...... ............ . ......... ......... --7 --------------------------- ----------­-------- - - - .................... ................................................................ ................1_4......... ... -------------- Nature of Repairs or Alterations—Answer when applicable................P_j.. --------- U I t. . ...... --- i9'..j............. ---------------------------------------7................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TJITI Uj 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has I een issued by to b)o;lr4 of health. Sir W_wmlnk-- Application Approved By....-42 ........ ....... . ...... ......... Date 11��-—--------------- I Application Disapproved for the following reasons:.....................................................................................7.................*-------- ..............................................................................................................................7..........w.............................................................. Date PermitNo......................................................... Issued... .......................... Date In No......L --._....... FE$.............�........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Uiiposal Works Tonotrurtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: ........................... ... -----------........----•---------- ...---•--................._..._..-----... Location,=Address 11or Lot No. • ......................................................•-•- r Owner j—' Address M Installer r Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures --------------------•---•------- ----------------------------------------•--------------•--•-•------........... Design Flow__________________________ gallons per person per day. Total daily flow_._r (...............gallons. W g .................g P P P Y• Y ....................... Septic Tank—Liquid'capacity___._____._.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b . --------------------------•-•• Date Y Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch, Depth of Test Pit.................... Depth to ground water........................ �+ •--•-------------------------------------•----------------I..........••----------------... ........................••--- 0 Description of Soil-------------- V .................. ----...------._.._......---------•-----••---....._._.__....._...:-----._....---------...--------•----.._:.-_..---._...-------•--•---...---•------..._........-----------••------•---- W U Nature of Repairs or Alterations—Answer when applicable.:______.?_.... ................................._,}._.._.`!:_:�..'. .'........................ r --------•------------•------•---------=-------------------•-.._._..---•-------------•-----•--------------------------------------------------••--=--•--•---•----•------._._......__.......__.._...-----• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the.provisions of TITI.i�. 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. Sinf ........................... �.�'�11.�A................. ................................ � �A • ............. ��Uate pplication Approved BY--- & 4 •-------•- ----•- --M- --- 7 Date Application Disapproved for the following reasons:..........................................._.................................................................. - ••---•---------------•-----..._.....--------•----------.,_...---•---------------•---_......•-----------•--•••-•-....__.._...•---•---------•-----•----------------------------------•••---••-----.._..._ Date Permit No...................................................... Issued`_-........ -- �� 1d.................. .,t Date "t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .E: :... '.........OF... .............................................................. (Xrr#ifiratr of floutplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (?:;) DUI//'*t'i �'---• Installer lri ... . ,, !. has been installed in accordance with the provisions of �o�The State Sanitary'Code as described in the application for.Disposal Works Construction Permit �o____________ ___________________________ dated___.,[."1 ................................ T THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEIWILL FUNCTION SATISFACTORY. DATE....._..... �d :Inspector 41144444-11 � y. •.r-trn --�°�R fir:- ..+,'�a'a a ..+:.-.,:.w..-�...Wiii:'Z'hiSsGisa'�'i'di2'`-..�-.s�.:e.w..r:mea._b:t. ''•, '. f,�i,' ...._,- .C�w I THE COMMONWEALTH OF MASSACHUSETTS BOARD_ OF HEALTH d�. - CAE f ................... ��, ! '�-� No._..--. --•••• FEE.......... -..... �io�os�tl: �rko �onot��trttitttt. �eruttt Permission is hereby granted ==-"_}r__ 1 Of..! 1 ...........................)-...-....................................•-•--- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System `'" at No...1 C,r?_l; ) T r- � 1 1 f/ �'I i� )��r / ,I"�/il�,.:��-�,`1 ; (:.(.fir) 1 1 Street -`'-- as shown on the application for Disposal Works Construction e�tN ___ .______ Dated_____=. _� d .- :.....................•••...__._ Q' //I7 Board of Health' DATE......... ------------•-•�•�-Lo*............................................. f/ FORM I25'S HOBBS & WARREN. INC., PUBLISHERS „