HomeMy WebLinkAbout0024 WOODLAND AVENUE - Health 24' WOODLAND AVE.
HYANNdS
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TOWN OF BARNSTABLE
LOCATION SEWAGE
uIl.LAGE ff�r a > ASSESSOR'S MAP & LOTQQq
INSTALLER'S NAME&PHONE NO. %
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 11t (size) 30���xJ-�
NO.OF BEDROOMS 3
BUILDER OR OWNER
„ I
PERMITDATE: Idoo COMPLIANCE DATE: OO
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 '
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Zpprication for Mig og *pgtem Construction Permit
Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) [�.Qomplete System ❑Individual Components
Location Address or Lot No.2 fit.10U J9 / y Owner's Name,Address and Tel.No.
c
Assessor's Map/Parcel / I�( f S Jf7F-
Installer'_s Name,Address,and T Designer's Name,Address and Tel.No.
/t}C T,
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3}0 gallons per day. Calculated daily flow 3k9 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1�� So 1'c Type of S.A.S.NAA cg tt
Description of Soil a4z CUUA-K s3e /C 4t,-v
Nature of Repairs or Alterations(Answer when applicab ) S, T-c &60,< awl✓2 0a5
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 Environ Lnd nd not to place the system in operation until a Certifi-
cate of Compliance ha issued by this Boo 1-a lea
Signe Date r °�
Application Approved by Date
I%." — , - - - - —ZL2'a
Application Disapproved for the following reasons
OP
Permit No. Date Issued
a► �J
No._ .. Fee
• THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
1= Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppCtcation for Migwog z *pgtem' Construction Permit
Application for a Permit to Construct( )Repair( 4pgrade( )Abandon( ) [�Qmplete System ❑Individual Components
Location Address or Lot No.,c Yong0 k,.-Z
y Owner's Name,Address and Tel.No.
Assessor's Map/Parcel /7 Ise)
�wt 5 ���
Instal s N�(ne,Address,and T NO. Designer's Name,Address and`el.No.
;�Tc),j 1 S Sr, f4 '
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3�� gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank,�1 � 0 911 Type of S.A.S. Cat �cGIT t 1,
Description of Soil !/V-� c-CA rl s-e l C P"-y
Nature of Repairs or Alterations(Answer when. applicab ) U St J `
r� Ac,T 'w ,C�1"✓a"�cl7S Gv C.(1 5771�.�yu�-Si/Jvf tic- !,ti 19
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 Envir mental-Code-a not to place the system in operation until a Certifi-
cate of Compliance h en.-issued by this Boar He
Signe j G Date 7
Application Approved by �lr 1 B Date
- Application Disapproved for the following reasons
-6z
Permit No. Date Issued
---------- -----------
~' THE COMMONWEALTH OF MASSACHUSETTS
�~ BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CER 1 e 9tf fiite Sewage Di pos�ystem Ponstructed( )Repaired( )Upgraded
Abandoned( )by �d[[ a10��
at W001O ha b constructed inaccordance
with the provisions of Title 5 and the for Disposal System Construction Permit No
Installer Designer
The issuance of this permits all no-�Mcons. ed as a guarantee that the sy tem AM
uncti on a des'gnedDate 1/ Inspector �
No. Fee
k THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
migpogal &pgtem C ongtruction Permit
Permission is hereby granted to Co truct( )R``e ( ) pgrade( Abarylf n( ) r
System located at Ujoo
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.
Provided:Constructi n u be-co pleted within three years of the date of ✓pe it./
Date: V Approved by i`
A
TOWN OF BARNSTABLE
LOCATION - GrJnn/1 LouO SEWAGE # 1 'o �-
VILLAGE �iq a ASSESSOR'S MAP & LOT
c�p/"— F`
INSTALLER'S NAME& PHONE NO. . �j t
SEPTIC TANK CAPACITY ``'�
LEACHING FACIL=: (type) Nyh �1/1�+�>yJ;�sT C (size)
NO. OF BEDROOMS 3'
BUILDER OR OWNER
PERMITDATE: 0 COMPLIANCE DATE: DO
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facili
ty (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist st
within 300 feet of leaching facility) Feet
Furnished by
e
oa o
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. ,
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, J hereby certify that the application for disposal works
construction permit signed by me dated I o , concerning the
property located at 2- 4meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface
Elevation(using GIS information) �
B) G.W. Elevation v +the MAX.High G.W.Adjustment]t0/
= C��
DIFFERENCE BETWEEN A and B
SIGN DATE: I V
[Please Sketc prop sed p an on back].
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
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NAMJ f 7 FL!'>AD A '; Co ;fit BAR 51377
TOWN OF ADDRESS 0 END Ai S„rk!I
BARNSTABLE CITY,STAT Z E V j'(,) �`,.lyA Th\�
�.tXE ip� MV/MB REGISTRATION NUMBER
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BARNSTABLE. Ijdil] �/.w�• CL
4IA55.
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TIME AND E 0 IOLATION LO ATI N F VIO ATION QZ
NOTICE OF A FORC P,P.M: , : •)oN, IODLAD
y I
VIOLATION SIGN TUR� Ir��► ON Gp /� ENFOR N D BADE W
1f4+' N
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OF TOWN H REBY ACKNOWLED,Gf RECEIPT OF CITATION X a
ORDINANCE Unable to obtain�sig atur o offe er. THE NONCRIMINAL FINE FOR THIS OFFENSE IS S ~
Date mailed J
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OR YOU HAVE THE FOLLOWIN ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPITON(1)OR OPTION(2)WILL OPERATE AS A FINAL °-
DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w
REGULATION Q
(1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, w
before: The Barnstable Town Clerk,367 Main Street,Hyannis,MA 02601,or by mailing a check, money order or postal note to Barnstable Clerk, J
P.O.Box 2430,Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE.
(2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,
FIRST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA02630,ytt:21 D Noncriminal Hearings and enclose a copy of this citation
for a hearing.
(3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the
hearing to be due,criminal complaint may issued against you.
❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in Ahe amount of$
Signature
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TOWN OF BARNSTABLE BAR-W 3774
Ordinance or Regulation
WARNING NOTICE
A prc) P &/
Name of.. Offender/Manager L��'
Address of Offender ,_ /i. N MV/MB Reg.#
Village/State/Zip 1/ A A17, ffio� (J > f /
Business Name �_a C/pm,/,on , 11V 2Q /
Address ,+'� �.f� ° w
• /Signature of�'�E`iiff`orci,ng Office'rJ
Village/State%Zip
Location of Offense t , ,/ C � " � `/
aj► " f r t V Enforcing /Dept/Dibvision'
Offense
Facts fl AINV { a 1�"? l � ;`�i b V RO �n n 6,
4 )t` 1/ram/r / t (i'> 66.1 -
This will se rve' only as a"warning, At this" time no legal action 'ha's been takeen
It is. the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
k.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT:
TOWN OF BARNSTABLE BAR-W $7 4
Ordinance or Regulation
WARNING NOTICE
Name -of. Offender/Manager " �,.,3 (��. 't
Address of Offender 71A r , , , 1 �"'�.7 MV/MB Reg.#
Village/State/Zip ,l All n),
Business Name '7W20
«-^, am/pm, ,'on
P d t q F+✓�
;Business Address
'Signature of-Enforcing Officer'
Vill age/S.tate%Zip f
Location of Offense + AM , 1 ', i .. s�'' .i./*
rf
0 ' 0 Enforcing Dept/Dinvision'
Offense � - � . . ° ri
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Facts ,) `;4T "� C. a. ' d`�.r 1 ` ;' u ! (
P-�,
}'� y yam•' ,�'� �r,�y
This will serve' only as a warning, At this" time no legal action has been taken. ..
It is, the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by ;the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
Y TOWN OF ZARNSTABLE BAR-W
Ordinance or Regulation
NOTICE 0,02 I
'� ' WARNING NO E C �
Name of Offender/Manager 4'+, x. i l ( k'
,r
Address of Offender r °"�✓ v` I MV/MB Reg.#
Village/State/Zip ( " ,''
ll
Business Name am/pm;�on��f,�A 20
Business Address ~� ,�
Signature of Enforcing Officer
Village/State/Zip
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Location of Offense � ,��".�:_.�� ��."' I�' �` _ �� �'�.`5�f�, '�g� ����°I
.. I E fo cin v
,r g Dept/Di ision
Offense
Facts 4 `Z, '1 ' { -.�. d' olfiw/'//-i� '( VIN
M yt"'Jr i i 7
... 4
' ThisVill serve • nly as a warning. At "ths time no legal 'acton has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
,,t34` WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-•ENFORCING DEPT.
TO ol�l U/lJlTIME ,�\ AM
M
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EXT.
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SIGNED
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PHONED l BACK CALL RETURNED EE YOUO AGAIN ALL WAS IN URGENT
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r , TOWN OF BARNSTABLE BAR-W MO. 3799
Ordinance or Regulation
4
��� WARNING NOTICE go,
Name of Offender/Manager g # ' � C"
Address of Offender ,44. a ) I A Alawl yr'-, MV/MB Reg.#4H -,
Village/State/Zip ''! � . I r ? ✓ �
Business Name f, o t !a/pm;, on ,. Ld 200
= Business Address
' T Signature of Enforcing Officer
Village/State/Zip x ,�
l� Location of Offense °` f ( ' P r + rw f
Enforcing Dept//Division
Offense.`
Facts
,1�"
wn
Opt
Thi's will serve only as a warning. At' this time 'no,' lega4l acti16n has been taken.
It is the goal of Town agencies to achieve voluntary compliance ofa Town
Ordinances, Rules and Regulations. Education efforts and warning noticesIa'P
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
0.42 �
SHEA,JAMES A t' 101 i
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Health Complaints
10-May-01
Time: 9:20:00 AM Date: 5/10/01 Complaint Number: 2849
Referred To: DONNA MIORANDI Taken By: DONNA MIORANDI
Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH
Article X Detail:
Business Name:
Number: Street: Woodland Avenue
Village: HYANNIS Assessors Map_Parcel:
Complaint Description: House overloaded with Brazilians that have
tons of trash on their property.House is third
one in from the right coming from West Main
Street.
Actions Taken/Results: O
Investigation Date: Investigation Time: r
r
1
d
1
r TOWN OF BAMSTABL a�/"'AW �°'�j+°,
..0 IATION c L >� SEWAGEUk#t
1ILLAGE ASSESSOR'S MAP & LOT `' `Y
INSTF ,LER'S NAME&PHONE NO._a r i2C�i>h -�'p -�C
SEPTIC TANK CAPACITY / 'u O
LEACHING FACILITY: Y
) Xs✓ji�� ��/�'� (size)
NO.OF BEDROOMS "
BUILDER OR OWNER
-SRr,A
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facili ) - /�Q U/61— Feet
y, Furnished by/l/OT�:35a Gtl / A/h 1j�s a�l �0 �'2-(LX
Zd�
3-
Lot
c�.a
YOU WISH TO OPEN A BUSINESS?
LFor-Your Information:. Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
by.M.G.L.-it does not give you permission to operate.) Yo.0 must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
e completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
by law.
DATE: �� Fill in please:
... ;_. APPLICANT'S YOUR NAME/S:G'i:� i 5 i i n,I.JG ►JD ti U e S
,.; BUSINESS YOUR HOME ADDRESS.;),,I., WOOD L A U -D A U E
t C502,)a���o 'a 150 �) do �, �3 i 4c�
ci� TELEPHONE ## Home Telephone Number
I A01
NAME OF CORPORATION: P I hj T_
NAME OF NEW BUSINESS TYPE OF BUSINESS I I
IS THIS A HOME OCCUPATION? YES I_NO
ADDRESS OF BUSINESS a �CJ 1. 0 ok-y�Ck \tc. C�YI MAP/PARCEL NUMBER Gam' (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the.information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth
Rd. & Main Street) .to make sure you have the appropriate permits and licenses required to legally operate your business in this town'.
1. BUILDING COMMISSIONER'S OFFICE
This Individual has be n i rmed of 2yermit requirements that pertain to this ty e f i B
'�rU PeMPLY WITH HOME OCCUPATION
Authorized Signature** ES AND REGULATIONS. FAILURE TO
COMMENTS: 1 ' Y MAY RESULT IN FINES.
2. BOARD OF HEALTH
This individual has.been informe of the permit requirements that pertain to this type of busine MUST COMPLY WI-1
WARDOUS MATERIAL.:
Authorized Si tvu
gnature** LATIONS
COMMENTS:
--------------
S. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This Individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
/ I
TOWN OF BARNSTABLE Dateog//d-
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OFBUSINESS: C .e IJ
BUSINESS LOCATION: L Waa6I L A ?r ilk , INVENTORY
MAILING ADDRESS: 7 I,{ Wood L4 Ad A- 1r� , TOTAL AMOUNT:
TELEPHONE NUMBER: �d �-� 'Ld 2>o/4c9C, Uo 3 r t[O
CONTACT PERSON:
O
EMERGENCY CONTACT TELEPHONE NUMBER: Spg 94 loZw MSDS ON SITE?
TYPE OF BUSINESS: /yt//Vg,
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
L Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
Citizen Web Request Page 1 of 3
C9
Arl
Logged In As: Citizen Request Management Wednesday, November 2 2011
TOWN\oconnnneft
Route to Users Search Requests Create Requests
Request Information
Request ID: 36048 Created: 10/31/2011 11:03:53 AM
Status: Assigned To Staff Assigned To: O'Connell,Timothy
Health Office
Anonymous: No Request Category: Chapter II : Housing Substandard edit
Routine work: No Estimate: No edit
Date scheduled: edit
Estimated 11/15/2011 Change Estimated Oct November 2011 Dec
Completion Completion Date:
Date: r03
Mon Tue Wed Thu Fri Sat
31 1 2 3 115
7 8 9 10 11 12
14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 29 30 1 2 3
4 5 6 7 8 9 10
Created By: Parvin, Lindsay Priority: Medium edit
Health Office
Citation Numbers: edit
Requestor Information
Requestor
Request Parcel Number Map: 269 I Block: 158 Lot: 000 j
Requestor reports that the rental
unit has no heat and is infested with
rats. Requestor has reported the Parcel Lookuo
issues to the landlord but has not
gotten a response.
Email:
Edit Requestor Information
f
http://issgl2/intemalwrs/WRequest.aspx?ID=36048 11/2/2011
L
Citizen Web Request Page 2 of 3
Track Request Progress
Request Work History: Internal Note History:
Entered on 11/1/2011 9:19:02 AM Entered on 10/31/2011 11:03:53 AM
by O'Connell,Timothy by Parvin, Lindsay
On 10-31-11 went to said property with Tim,this was reported to us by Joe Burns of
owner, occupant,and translator. Heat had been the Cape Action Committee, 508-771-1727 ext
restored once I arrived.There were other 128. He called on behalf of the requestor because
violations which have been documented and an the requestor does not speak english. Mr. Burns
order will be sent out. reports that somebody from their agency visited
update delete the site and did observed rats.
System entry on 10/31/2011 11:03:53 AM:
Assigned to O'Connell,Timothy
Enter work progress: Enter internal note:
(Viewed by everybody) (Viewed internally only)
153
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Time worked on request: 2.00..._ Response time: 2.00
......... ......
*Time entries are in hours. Examples of time entries: 1.25, 0.5, 0.75, 1, 3.5, 0.25, 0.10
* Response time: Measured from the creation date to your first actions on the request.
* Do not include nights,weekends,and holidays in response time for most departments.
r Save changes 17 Check to notify town employee below
to review this request.
Save changes and notify Health Office C=
citizen* ..._...... _.__._____..._..._....._..__.___._._................_
Crocker, Sharon I
t;Close request _ _ .T_ ..._. _...
r,Close request and notify citizen* Brief message to reviewer: 1-
*notify works if email address was given `
http://issgl2/internalwrs/WRequest.aspx?ID=36048 11/2/2011
.....................
THE COMMONWEALTH OF MASSACHUSETTS
I E3•OARD OF HEALTH
OF...IJ C --------------------------------
o`� A liratinn -for M_q osal Works Cnoustrurtion Vrrufil
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
Loca dress r Lot No. `
O Address
.
r- - Installer Address
UType of Building Size Lot---------__________.........Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons......................__---- Showers ( ) — Cafeteria ( )
Otherfixtures ----- .............--------------•----•-------------------------- -------------
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. it.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------- --- -••--_....... .......................................... Date--••------•------------•---------------
Test Pit No. 1----------______minutes per inch Depth of "Pest Pit------____.......... Depth to ground water.._._.-.-------____.___.
114 Test Pit No. 2________________minutes p inch D t f Test P .........._......... Depth to ground
a water......_.-__--_.__-----_.
.••••-
O Description of Soil.-.-_-__ r_.�
x
W
x ------------- ------- ---------------.........=.................... ------------------------------ ---------- --------- ---- ----
U Na re of Repairs or ltprations—A �w when applicable.,_ ----- - �, .-7 (�-_._.
-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
1l the provisions of Article XI of the State Sanitary.Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b9n issued by the board of he
� 7
Sign e• ...er �__. a
Date
Application Approved By..---- - --- •--•................... ------
Z•t_ .
Date
Application Disapproved for the following reasons---------------- % . ------------------------------------------------------------------
---------------------------------------------------------------------------------------------------- -------- ------- ------ ---------- -------------------------------------
SV Date
Permit No. Issued.... .........--•--•---••- ..........
Date
a FrEII:.. ... ....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............OF... ...............................
, pphrtttion -for Bigpuiittf Works Tomi#rurtion Vrruift
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
_ _. _ . .,f.... • I.'-- ••-•- ,',,,.,.. , ..................................................
Locat' — ddress or Lot No.
O er
fW1 ---'��.....�`W:_�r Address .---- --•-•-
P' ••
nstaller Address
UType of Building Size Lot-------------_...........___Sq. feet
Dwelling—No. of Bedrooms__.....................____-----------_-----Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building _---------------------_..... No. of persoiis Showers '( ) — Cafeteria ( )
Other fixtures ____:a-----------------
Q -------------------------------------------------------------------- -------- jr
--------------Design Flow_____________________________ k ___ gallons per person per day. Total daily flow...... I -.-gallons.
�� C P y
WSeptic Tank—Liquid capacity " ;.__gall'otis Length----_.......____ Width---_-........... Diameter ;ice Depth
x Disposal Trench—No......................Vidth _________________`Total Length........_:_.......
.. Total leaching area .... __ .._____sq. ft.
Seepage Pit No_____________________ Dtamet`.x Depth :below• inlet =______.____ Total leaching area__.__..__.:_.___sq. it.
z Other Distribution box
Percolation Test Results Performed bye' ._....`'__ Date..............:.
Test Pit No. .........-.minutes per inch Depth' of Test.Pit_..........
;__a Depth to ground water----------___...__`x:...
G4 Test Pit No. 2....._..........minutes p inch `D f,..':C,est P ..__._.._____.____ Depth to ground water-_._--_._______-_-__-. -
D Description of Soil :. `Is,�
x
U
w
U Na re of P.epairs or Iterations—A when a plicable. _____ �^
g
reement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued bX,the board of e
Signe 't �.y�. -•--••• !L,?
�!�s Date
A lication A roved B ^' '' / —.-
PP PP Y ,�^ �I ------•------ {s.....
+ 'r�Date 'S
/ s
Application Disapproved for the following reasons:ar..................'_
-------------------------
^r v
- ..............
Date
PermitNo......................................................... Issued.............--------- ............... .............
Date
THE COMMONWEAL\rH OF MASSACHUSE TTS
BOARD O HEALTH
.: - � ..........OF...........
Tntifirttte of 011omphaure
T CE T FY, That the Indi uaJ/.9ew ge Disposal System constructed ( t) •br`"Repaired ( )
by 7en
---•- -•• -----
Install
has bnstalled in accordance with the provisions of Article XI of The State Sanitary ode a described in the
application for Disposal Works Construction Permit No------2.J.6— dated..,, _ -�.__ ....'-lam ""__••---••••--
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector -'
.. . ..� .�. ... _ .� .. ,.._..._%g...'7.�".,�"a�ntr.. _... ^_..... _ .. - _... ..__. �..,__•-..�u....a��:.,,it!S°"d'�t�Nwt'Ct44.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
FEE.......................
DI-tivaiial lark n r11r�ioat i
n
Permission is hereby granted Y •. •-•- C ..
to Cons'trtht ( ) or Repair rr an Individual Sewage Dgis�po�al ys t �
at No... �Rp,A,y --___ .........
Street
as shown on the application for Disposal Works Construction it No Dated... ."_ _'�_____________________
/ rr.. oard of Heal j, •-=----•`--...�
DATE.-- .......:......
FORM 1255 Hoses & WA'.R R,EN.: INC.. PUBLISHERS "�