HomeMy WebLinkAbout4075 FALMOUTH ROAD/RTE 28 - Health (2) 4075 FALMOUTH R(7
h
I
I
i
i
I
i
TOWN OF BARNSTABLE., � v
yOCATION L/d7S �,-p-L, SEWAGE #
VILLAGE ��-yt,-�' ASSESSOR'S MAP & LOT 6`/0" 03-i�F
INSTALLER'S NAME & PHONE-NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) fit ' _(size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER V�j
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
CCh
i
v
i
IN I ,�� � 1 l:•<` _l: �
k
I✓ S b ti ?M1..
I
� I
I -
I CAP- t VivEYARD ELACT •EHSEA' A_7 II
. I
ARK 1 M �\J
t f- ._-tic l �, ` — t ALLOIt
�
t V 1 1 .� \�.: tf u ! 7J SF_VTIC -TAN K N
D'Go•c •:
• 1 t i3 Fo1�NVATtoN g + -
1 01 , 1ptcP. U.4r-,/Z SE ---
_ Z
i
ui
F I I Z t (lt�
1 \1 -
�- -.— DISTANCE AS CERTIFIED F 5
I HEREBY CERTIFY THAT THE BUILDING -SITE • PLAN -- -
lOs'j'q ON THIS PLAN IS LOCATED ON THE
+OUND AS SHOWN HEREON & THAT IT G f I LOCUS: -
)r,FOF1M TO THE ZONING U LAWS OF THE At` NU_ 2-2 8Z 4 ENE E-r - =
Of
�iEr.; G REF:
.ONSTRUCTEO. DATE Gf=r/F L I y!Y1�H \( 1\v -2 a C_0� L) l t
/C7 AR iE J% --- T'Q1` I t T f \ / �\
C[+✓(%/% C01)e C'/J� } H•i '.? PREPARED FOFi: _ `J- . _r
CIVIL ENGINEERS - -
LAND SURVEYORS
�AN[ $Uf} VG/A } s 1� / `s
\` l `•"IS
'� 4L' SCALE--' ---�() -- FD/A_- 7C
Yn,,i�ulh F. O,Ic•rns,MA 9 %.-`� DATE f / �—
�. I .—
No. 'i Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Migpo.5a1 *paem CCon5truction Permit
Application for a Permit to Construct(pair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1/0 75,9T Owner's Name,Address and el.No.
>>'Cot c�s-�
Assessor's Map/Parcel D
Installer's Name,Address and Tel No.S-2N3--/`l0—g7_3W Designer's Name,Address and Tel.No. '
Jos eP" 0,
mot'
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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) rll.5 r01 /1//:4L' 1_-1-20 0"aGA
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 Certifi-
cate of Compliance has been issued by this Boar of ealth.
Signed Date
Application Approved by - JWZZ�fflMDate
Application Disapproved for the following reasons
Permit No. Date Issued
lL/ V } .y s_..... 7
No. � � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
0(ppYication for Mood * tem Con!5truction Permit
Application for a Permit to Construct(:;.)'Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components
Location Address or Lot No. 4Q) 7 5r,r\r u Owner's Name,Address and Tel.No.
V��t1�'f�J
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No.,��Ci' '?0 C Designer's Name,Address•and Tel.No.
I 17--
Type of Building:
i
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building -No. of Persons Showers( ) Cafeteria( )
T Other Fixtures '
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 'r,5l_Y 7"'0/11V1_!F/ /-1-20
Date lasf'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 Certifi-
cate of Compliance has been issued by this Board o��f,,iH�ealth.�
Signed t , . !?s i""/ � Date
� _
// � .�/• / � �
Application Approved by Y r"lam% _ ! 4 Date
A
Application Disapproved for the following reasons
Permit No. Date Issued 3yco
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFthat the On-sites Sewage Disposal System Constructed( ) Repaired( )Upgraded( )
Abandoned ( )by
at 40 7 5 R ti.. 15 V 6— hnarbe constructor in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated ✓ `}
Installer Designer
The issuance of thiyoymit shall not be construed as a guarantee that the syst me ,''Fill function as designed.
' Inspector.'Date -
No. Q� i --------------------
Lq ——————Fe e
70��-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Migpozai *p! tem �tCon5truction Permit
Permission is hereby gra tee t C str&t . ) pa�( )!r!System located at (� D zf
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: Construct mus,be c mpleted within three years of the date of this t
Date:_ O Approved by
r
Town of Barnstable -
PROF THE Tp��
Regulatory Services -
,Au,siABLE ; Thomas F. Geiler, Director
9 MASS. g
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
March 23, 2006
Ms Susan Sarafm Perry, TR
c/o Wolf Realty Trust
P.O. Box 270
Marstons Mills, MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5
The septic system owned by you located 4075B Rte 28, Cotuit, MA, was last inspected
on March llth 2006,by, Michael O'Loughlin, a certified septic inspector for the State of
Massachusetts.
The inspection of your septic system showed that your system has "Fails"under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
All structures are H-10 loading.
Not designed for vehicle traffic.
You have 2 years from the date of the system failure to bring the system into compliance.
If there are any questions about this reminder,please feel free to contact the Barnstable
Health Department.
BARNSTABLE HEALT DEPARTMENT
ma A. Mc ean, R.S., C.H.O.
Agent of the Board of Health
4 �
� � I
U- Allo
?� COMMONWEALTH OF MASSACHUSErrS
C EXECUTIVE OFI�ICE OI, 'N'\'IIZONMENTAL ArFAIRS
DEPARTMENT.' OF ENVIRONMENTAL PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARI' ASSESSMENTS
SUBSURFACf, SEWAGE DISPOSAL SYSTEM FORM
fYI o�1G—'-32' PART A
CERTIFICATION
Property Address: 4 Q
Owner's Name:
Owner's Address: 1-1
�two.►n 1 Qom,Yy� o�G 5 5
Date of Inspection: 3] �
Name of Inspector: (please print)�1 [���' .,9
Company Name: U
Mailing Address:
5
Telephone Number: - 36
I'V(.ck,. 0"-7
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:
Passes
.—/Conditionally Passes
Needs Further Evaluation b) the Cocal Approving Authority
Fails
Inspector's Signature: C) Date: 5)1, b6
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
gild or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DER The original should be sent to the systemowner and copies sent to the buyer, if applicable,and the approving
authority. i '+
Notes acid Conunents ZE
� .
j
ya
****This report only describes conditions at the time of inspection and under the conditions of usl at that,,,-,,,, ra-
time. This inspection does not address how the system will perform in the future under the same o different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Y CERT1ITICATION (continued)
Property Address: S
Owner:
Date or it, pection:
Inspection Summary: Check A,13,C,D or- E/ALWAYS complete all of Section U '
A. System Passes: `
J have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated arc indicated below.
Comments:
Ii. System Conditionally Passes:
One or more system components as described in the "Condition be relaced
repaired. The system, upon conrpleUon of the replacement or repair, asrapproved byal Pass- rthe Boardoll neelof Health, willrpass.
Answer yes, no or not determined (Y,N,ND) in the for 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 irrrminent. 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 sta
tic water level illto
obstructed pipc(s)or due to a broken, settled or uneven distribution box. Systcmlwill pas inspection irf(wibioken or
approval of Board of Health):
broken pipc(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipc(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipc(s)arc replaced
obstruction is removed
ND explain:
2
y Fr
:Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
,C;ERTIFICATION(continued)
Property Address: yD 7
Owner:
Date of In ection:
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, irany)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 systern (SAS)and the SAS is within 100 feet of a•
surface water supply or tributary to a surface water supply.
— The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank arid SAS and the SAS is less than 100 feet but 50 feet or more fronl a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis, performed at a DLP certified laboratory, for colifor-rm I
.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 pprn,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
• 3
Page 4 of 1 1
1,
OFFICIAL INSPECTION FOIZM —NOT FOIL VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PAIZT A
CERTIFICATION(continued)
Property Address: T?
Owner:
Date of Ins, ection: 1
D. System Failure Criteria applicable to all systems:
You trust indicate "yes"or"no"to each of the following for all inspections:
Yes No
_ Backup of sewage into facility or system component due to overloaded or cloeecd SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ Static liquid level in the disU-ibution box above outlet invert due to an overloaded or clogged SAS or
••rr cesspool
N Liquid depth in cesspool is less than G"below invert or available volume is less than day*low
Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
/ of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
f�1$ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. .
.t U Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well. .
u 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 colifornr bacteria and volatile organic compounds
indicates that the well is free from pollution front that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 pprn, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(Y /No The system fails. I have detennined that one or more of the above failure criteria exist as
scribed in 310 CMR 15.303, therefore the system fails. The sy5tcm 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 syste►n the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ 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 systern is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a trapped
Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the systetn in accordance with 310 CMR
15.304.The systern owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 1
OFFICIAL INSPECTION FOAM — NOT FOIL VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
I'AIt'I' ll
CIIECK.LIS7'
Property Address:
Owner:
Date of in Pliction:
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Y No
Pumping information was provided by the owner,occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks ?
V1 Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(lf they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out ?
Were all system components, excluding the SAS, located on site ?
t/ _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systents
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yet. no '✓ _ Existing information. For example, a plan at the Board of I-icalth.
Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b))
I
5
Page G of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Ills, cction. 6
F
RIs'SIDEN'17A L LOW CONDITIONS
Number of bedrooms(design): Number of bcdrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x N of bcdrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):_
Is laundry on a separate scwagc system (yes or no):— [if yes separate inspection required]
Laundry systcm inspected (yes or no):_
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy:
COMMERCIAL/INDU TRIAL
Design flow(based on 310 CM R 15.203): rd
Basis of design flow(scats/persR 15 0 etc 6I
Grease trap present q )
F F (yes or no _
Industrial waste holding tank present(yes ore).
Non-sanitary waste discharged to the Title 5 systc (yes o no
Water meter readings, if available: . 05- 4a.1000 Q� pef _ 4Dt DoID
Last date of occupancy/use: — IML
OTHER (describe):
Pumping Records GENERAL INFORMATION
Sou rccofinformation: r,>,. y
Uc
Was system pumped as part of the inspection (yes or now): —G'_te� dL_U�
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYI OF SYSTEM
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 systcm owner)
—TighLtank _Attach a copy of the DEP approval
—Other(describe):
Approximate agc of all components, date installed(if known)and source of information:
t
Were sewage odors detected when arriving at the site(yes or n :
Y 6
I'rge7 of' I1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTI?M INSPECTION FORM
PART C
SYSTI{n1 INFORNIATTON (continue(l)
Property Address: 4D?
Owner: -----
n.
Date of Ins ection: l (�
BUILDING SEWU;R(locatc 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: Zlocate on site plan)
Depth below grade: 1
Material of construction:-Zconcrctc_metal __fiberglass __polyethylene
—other(explain)
If tank is metal list age:__ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: lOUO n�
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to botto i of outlet (cc or baffle: II
How were dimensions determined: aa4Q& Q, _
Comments(on pumping recommendatior s, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of.Ieakave, etc.):
en WA
rw6m aim, 'Urn �v n OyLe, CAYAJVW ,
oP. � 9/z ouK6� lv��-�CowZY �'Y1 c� tUe,c.P av c��
.�.b� �
GREASE TRAP:—(locate on site plan)
Dcptlt below grade:_
Material of construction:_concrete_tnctal _fiberglass_polyethylene_other
(explain):
Dimensions:
Scwn 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(ors pumping recornmendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
M.�
Page 8 of I I
OFFICIAL INSPECTION FORM - NOT FOIL VOLUNTARY ASSESSMENTS
SUBSURTACE SENVAGE DISPOSAL ,SY,S 'I;NI INSI'LCTION FORN•1
PART C
SYST11"Al INFORMATION (contintic(l)
Pro perly AdJress: . 3JT_
Owncr: — -----—
Dale of Ins lcclion:
TIGIFF or• HOLDING TANK: (tank must be primped allime of inspcction)(locatc on site plan) .
Depth below grade:
Material of construction: __concrete—_metal__fiberglass .polycthvlene olher(explain):
Uimcnsions:_ — ------ -------- ---------
Capacity: gallons
Design How: gallonsmay
Alarm present (yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: ---
4mttlontc (aonditiort of nlnr-m nrtct (lone nwttehnn, rtc,):
DISTRIBUTION BOX: ✓ (if present must be opmed)(locatc on site plan)
Depth of liquid level above outlet invert:
Conullents(note if box is level and distribution to outlets equal, any evidence of solids carryover, 'lily evidalee of
Icaka a into or out of box,
PUMP CHAMBER: (locate on site plan)
Pumps in working order(ycs or no):
Alarms ill working order(yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, ctc.):
Y,
'L
Page 9 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM*INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7
Owner:
Date of In ection: 0
/
SOIL ABSORPTION SYSTEM (SAS): V (locate on site plan,excavation not required).
If SAS not located explain why:_
Typet7
leaching�pits, number: I — 6 y 6
leaching chambers, number:
leaching galleries,number:
leaching trenches,number, length:
]caching Gelds,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,
ctc.):
dL f " - '1'1 cx- ,
CESSI OOLS: cesspool must be pumped as part of inspecti )(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.):
9
Page 10 of I 1
OFFICIAL INSPECTION,FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner
Dale of In peclion: �
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including tics to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
3 33 3„
� 1$
0 cute, t�-t o ,,vLe` qvL Axz
10
Page 1 1 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Q?
Owner:
Date of In ection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from systern 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 docurnentatio
Accessed USGS database-explain: (1U_ l_A^tA C l
You must describe how you established the high ground water elevation:
O
a
t
11
Date: S I 113
TOWN OF BARNSTABLE �
TOXIC AND HAZARDOUS MATERIALS N FORM
NAME OF BUSINESS: K2A)
BUSINESS LOCATION: g07S 7:�a j,ivwvr-� Reel INVENTORY
MAILING ADDRESS: Aotx- TOTAL AMOUNT:
TELEPHONE NUMBER: .SDg - Y28-,5-02b 4,A6 w!5
CONTACT PERSON: -5�1 11�1- /J
EMERGENCY CONTACT TELEPHONE NUMBER:cell 5-oa -77/-3/15" MSD ON SITE?
TYPE OF BUSINESS: b vex
INFORMATION / RECOMME DATIONS: a v&�►c -o- W ►vLA L..)• HL, Fire District:
Servo A o Wzvc+5 4 C'o (_o- 'v ,-}-
3, AoVekoot lyw&o<5 s po,--e�
Waste Transportation: ��� Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals(Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt&roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform,formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous(please list):
Metal polishes
i S G• �to�J�-�o�� ��QA.vu-tS 2yl
Laundry soil &stain removers
(including bleach) d&Ac 5 +0 < Io gam.'
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
b�
o� ti00
00 F
Town of Barnstable
oFIME t, Regulatory Services
Thomas F. Geiler,Director
Public Health Division
BARN sTAs Thomas McKean,Director
MASS. g 200 Main Street, Hyannis, MA 02601
1639.
ArFO MA'1 A
Phone: 508-862-4644
Email: health@town.barnstable.ma.us
Fax: 508-790-6304 V
Office Hours: M-F 8:00—4:30 -
July 29, 2013
Ms. Laurie Needham RE: Vehicle Washing Wastewater Discharge
KON Limousine Service
4075 Falmouth Road
Cotuit, MA 02635
Dear Ms.Needham,
On July 24, 2013,Timothy Lavelle, Hazardous Materials Specialist for the Town of Barnstable,
visited your facility at 4075 Falmouth Road, Cotuit in response to a complaint. He discovered
evidence that vehicle washing with the use of soap has been performed in the back parking.area
of your facility. You were provided with a copy of the Town of Barnstable Vehicle Washing
Policy for your reference during the site visit. Please note that the Town of Barnstable Vehicle
Washing Policy prohibits the use of any cleaning agents including but not limited to: "chemicals,
soaps, degreasers or detergents" in the use of vehicle washing without an approved waste water
collection system. Also,Town Ordinance Chapter 108, Hazardous Materials, Section 9,
Prohibitions, states in relevant part that, "The release of any hazardous materials and/or acutely
hazardous materials upon the ground,or into any surface or ground waters or into any sewage
disposal system, sewer system, catch basin or dry well within the Town of Barnstable is
prohibited." This Ordinance was adopted to protect the public health and welfare,especially as it
pertains to the public drinking water supply..
As requested during the site visit, please develop an alternative method/arrangement for cleaning
your vehicles,which I understand is a vital component of your business. Mr. Lavelle is planning
a follow-up visit to conduct a full hazardous materials inspection within one week. Please have
your alternative plan in writing for review during that visit.-
The Public Health Division appreciates your cooperation and acknowledges your intent to
_ maintain compliance with the Hazardous Materials Ordinance. Please contact Timothy Lavelle at
508-862-4644 should you have any questions.
Sincerely,
Thomas A. McKean, RS, CHO
Public Health Division, Director
I
Town of Barnstable
OF THE A Regulatory Services
Thomas F. Geiler,Director
Public Health Division
sAxxsTAs Thomas McKean,Director
9 MASS. 200 Main Street, Hyannis,MA 02601
16g9. �0
ArFD��A
Phone: 508-862-4644
Email: health@town.barnstable.ma.us
Fax: 508-790-6304
Office Hours: M-F 8:00—4:30 `
July 25, 2013
Ms. Laurie Needham RE: Vehicle Washing Wastewater Discharge
KON Limousine Service
4075 Falmouth Road
Cotuit, MA 02635
Dear Ms.Needham, �;�, J 6a aj EDP "` d��
On July 24,2013, m response to a complaints kvehicle washing o-0,�
with the use of soa :iq being performed in the back parking area of your facility. You were
provided with a copy of the Town of Barnstable Vehicle Washing Policy for your reference
during the site visit. Please note that the Town of Barnstable Vehicle Washing Policy prohibits
the use of any cleaning agents including but not limited to: "chemicals, soaps, degreasers or
detergents" in the use of vehicle washing without an approved Waste water collection system.
Also, Town Ordinance Chapter 108, Hazardous Materials, Section 9, Prohibitions, states in
relevant part that, "The release of any hazardous materials and/or acutely hazardous materials
upon the ground, or into any surface or ground waters or into any sewage disposal system, sewer
system, catch basin or dry well within the Town of Barnstable is prohibited." This Ordinance
was adopted to protect the public health and welfare, especially as it pertains to the public
drinking water supply. ` n
As requested during the site visit,please develop an alternative method/arrang ent for c aning
your vehicles, which I understand is a vital component of your business. laaplanning follow-
to conduct a full hazardous materials inspection within abeam one week. Please have your
Wa in writing for my review during that visit.
e B 4appreciates your cooperation and acknowledges your intent to maintain compliance
with the Hazardous Materials Ordinance. Please contac __ tmte7ranT1or
should you have any questions.
Very truly yours,
�OFTNE Tows Town of Barnstable
Board of Health
BARNSTABLE, 200 Main.Street
9cb' 639. ��°� Hyannis, MA 02601
Office: 508-862-4644 Wayne Miller, M.D.
Fax: 508-790-6304 Paul J. Canniff, D.M.D.
Adopted September 5, 2006
Vehicle Washing Policy
Vehicle washing with the use of cleaning solvents, including but not limited to;
chemicals, soaps, degreasers and detergents, is expressly prohibited at any and
all automotive repair shops, bus companies, automobile sales businesses,
vehicle rental businesses, vehicle detailing businesses, municipal owned repair
garages, and any other businesses or government agencies where an approved
car wash system is not provided which meets all the Department of
Environmental Protection Regulations; 310 CMR, the Division of Water Pollution
Control; 314 CMR and the Town of Barnstable Code; Chapter 108: Hazardous
Materials. The spraying or rinsing of an engine or under-body of a vehicle is also
considered "vehicle washing". -
Exemption: Water from a spray nozzle or pressure sprayer
The use of water from a spray nozzle, pressure sprayer or garden hose to spray
potable water only (without soap) to rinse dust and debris from vehicles is not
considered "vehicle washing" for the purpose of this policy. However, the
washing or rinsing of an engine or under-body of a vehicle by any manner is not
.exempt, regardless of whether or not a spray nozzle, pressure sprayer or garden
hose is used for these activities,
Penalties
Failure to comply with the Town of Barnstable Code, Chapter 108:. Hazardous
Materials may result in a non-criminal ticket_citation of$100.00. Each day's
failure to comply with the Code shall constitute as a separate violation.
PER ORDER OF THE BOARD OF HEALTH
Wayne Miller, M.D.
Paul J. Canniff, D.M.D.
Q:\Ha=at\060906-Vehicle Washing Policy.doc,
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body shops
O unsatisfactory- 4.Manufacturers
COMPANY (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS- �',� K I lass:
7.Miscellaneous
QUANTITIES AND STORAGE IN= indoors;OUT=outdoors
( )
MAJOR MATERIALS : , Tanks
IN OUT IN OUT IN OUT #&gallons Age Test
Fuel
Gas line Jet Fuel
Diese Kerosene 2(B)
Heavy O'lS.
waste m for I (C)
new mo oil(C)
tra miss')n/hydraulic
Sy theticOrganics:
degreaser
Miscellaneous:
tell
fz:� &A!tt��
DISPOSAURECI AMATION REMARKS:
Q
1. Sanitary Sewage 2TPublic
ter Supply
�own Sewer i
On-site OPrivate
3. Indoor Floor Drains YES N01/ f ¢
O Holding tank:MDC_
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES NO O ERS:
O Holding tank:MDC
O Catch basin/Dry well
O On-site system ;
5.Waste Transporter
Name of Hauler Destination 'Waste Product
YES INO
2.
\4 ers s) n rviewed Inspector Date