Loading...
HomeMy WebLinkAbout62-64 FRESH HOLES ROAD - Health 62 - 64 FRESH HOLES ROAD, HYANNIS t A= ♦Rj Ly 1 I o 0 III f u I f k TOWN OF BARNST LE LOCATION �)--�7 SEWAGE # VII ,AGE fir«rt e� ASSESSOR'S MAP&LOT �bRR'S NAME&PHONE NO. SEPTIC TANK-CAPACITY LEACFIING FACIL 1'I'Y: (type) S (size) 5� NO.OF:-BEDROOMS BUILDER OR OWNER PERMITDATE: C©N011ANCE DATE: Separation Distance Between the: Maximum Adjusted GroundwaterTable to the Bottom of Leaching Facility _ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 2C9 feet of leaching facility) t Edge of Wetland and Leaching Facility(If any w7ti; within 300 feet f leaching facility) S� Feet Furnished by � r p✓� , .✓�� 1� '0 v� TOWN OF BARNSTABLE LOCATION G2- G y Frc:sk 14o)c S R,,L. SEWAGE# Zo 19 - 351 VILLAGE 5 ASSESSOR'S MAP&PARCEL 2q2 - 1'12 INSTALLER'S NAME&PHONE NO. -fJ F-Xeckyo.�i o� 4`l1-oG53 SEPTIC TANK CAPACITY /Soo !qa.l 1 LEACHING FACILITY: (type) S00!4o-) LIe 3l (size) NO.OF BEDROOMS q OWNER S)cnr;,s C'OC, nnrs PERMIT DATE: 12- Z) - 9 8 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 .i_ ,.. � . 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 Al— aw'/,,'' — 3�" AV r $Z. A3 '�� B3- ZG 1-;L A5' I$ 3s _ Z3 No. J Fee o v THE COMMONW ALTF OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppliLation for disposal Opstem Construction Permit Application for a Permit to Construct( ) Repair(✓f Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. (_p-T i$ f p2.'(04 Frp Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 2�2 - I`i2 -�o1�S Fresh 14olc RJ Installer's Name,Address,and Tel.No.Z A,.B EXaaL),L4 i0 n Designer's Name,Address,and Tel.No.6 CO- -rcc.-k Iy Tccxbc,rm4 LtJ Fores14c,\c. y`Y1- O 653 Type of Building: Dwelling No.of Bedrooms Lot Size 7 $13 sq.ft. Garbage Grinder( ) Other Type of Building Rc5,jcrN-a,a No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 14Ll C) gpd Design flow provided yss gpd Plan Date A)o v G 18 Number of sheets ` Revision Date Title Size of Septic Tank G, Type of S.A.S. SOO sjcL 1 LIc Description of Soil 5'6� n �� Nature of Repairs or Alterations(Answer when applicable) N20 0_90X- FI 1 O rN QC Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by rK W Date (ol 'l - Application Disapproved by , Date for the following reasons 1(p L(fr�5 71z t'�j ifjl %{ 5 f Y�J,�(� '�jJ V,?AA Permit No. Date Issued No.'arr1T � ' , + Fee loot THE COMMONMALLTTI OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE,' MASSACHUSETTS ftplication for Disposal-6pstem Construction Permit Application for.a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.'L� 1$ �� - (,q c esi Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel 222 _ I�o�2S R� . -f`n�5 e.'ar�not°'S 67.1, l F,,5�, R4 Installer's Name,Address,and Tel.No.Z.�,.Ba-1;a n Designer's Name,Address,,and Tel.No. C o. -rec�. (NTcaScm-q LYJ q-)-)• 0653 Type of Building: Dwelling No.of Bedrooms Lot Size `' ►► j sq.ft. Garbage Grinder( ) T , Other Type of Building Rc z,-�r n� ' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) !4y n gpd Design flow provided !45 gpd Plan Date A)o k l 4, I$ Number of sheets I j Revision Date Title Size of Septic Tank Type of S.A.S. -Sop Q,3 } i j Description of Soil Nature of Repairs or Alterations(Answer when applicable) � p 3n)( Ll C_ r 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. t . Signed oc_ Date . �t Application Approved by !h Q14"(e(115 Date a— Application Disapproved by r (_ Date for the following reasons ,JU S k r � 4�► __1 vl�L/,l P�t No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by C n, ;r--,r1 at - 47 Frr a4. Oc,Ir:S R• ,k has been constructed-in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Z,n I X'-g54' dated f!�--L/•.- Installer Designer CC(3L-rEr 1,J #.bedrooms U Approved design flow and The issuance of this permit shall not beponstrued as a guarantee that the system-Will functio s de ed. - Date 1 Inspector ------------------------------------------------------------------------------------ !--------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS r3isposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(,,o� Upgrade( ) Abandon( ) System located at 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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. Date� -� X Approved by { t Town of Barnstable Regulatory Services Richard V. Seali;Interim Director BAMnABM MM& Public Health Division 039• 1°jFe rra+" Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 G E Office: 508-862-4644 I Fax: 508-790-6304 Installer& Designer Certification:Form i Date: 12-20-18 Sewage Permit# Zo 18 - 3 5 i Assessor's Map\Parcel 297. 1`M Designer: ECO •-TEC-A Installer: Q fEXcv� -�io*� i Address: l55 Gcoroe Rw cr R0. Address: Jy -TcuSr-Mc4 L.P.:) Choi-�11c►.,ry1 �cc.s-��la.1t On EXceatw_A i o 1\ was issued a permit to install a (date) (installer) septic stem at based on a design drawn b sep c system G2-L�l fresh Icy g Y (address) dated tioV. L 18 (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. Strip out (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. Strip out(if required)was inspected and the soils were found satisfactory.: I certify that the system referenced above was constructs i ce with the terms of the I\A approval letters (if applicable) ����� ` s\ DAVID Q. MASON ; g(Insta1ns r' S ) No.10ISTE /T��Ft( esig Sign re) (Affix Designs tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc i it EXISTING SOIL ABSORPTION SYSTEM TO BE PUMPED AND ® REMOVED. REMOVE ALL ASSOCIATED CONTAMINATED SOILS AND REPLACE WITH CLEAN MEDIUM SAND PER TITLE 5. GARB G - oT SEPTIC � U�IG��L1OppAT R v- A OWED /` ECO- II ECW'lJS 48 PROPOSED SOIL ABSORPTION , a ® z o� SYSTEM 0 � off Eti -SEE DETAIL OSGS DAT©rASSUyE0 �B ° ON BACK : ELEVATION 49 mop 47.21 0� EXISTING SOIL / 8 °y �� OF CONCRETE, ABSORPTION - SYSTEM / ` oy 50 L LOOT 18 THIS IS A p I ` AREA 7813 sf+- 0 O �� COLOR �� ��LAND COURT PLAN 17786—C PLAN �L �`L ®�q\/!1' �( AS5R MAP 292 PCB 172 50 USE COLOR PLAN ONLY O v_ FOR INSTALLATION FULL DETAIL IS BEST � \ VIEWED IN FULL COLOR h. MINIMAL �. \•� � 1 LEGEND GRADING �I�OEEND Oo Q \PROPOSED � sTi \ �a> O O 2 i SEPTIC COMPONENTS 1500 GAL SEPTIC-TANK / . Fp DISTRIBUTION BOX® ` 40'9/L �/ 4 9 TEST-PI ( — - �-_ _. `� . - ��P4 y- - ­ --- it PLC AN SCALE: l in = 20 ft O 20 40 WATER LINE GAS LINE - INSTALLER SHALL PUMP 0 70 20 OVERHEAD WIRE—(off , TANK AT TIME OF PRINT ON 8-112 x 14 in e' INSTALLATION. & INSPECT PAPER FOR PROPER SCALE UTILITY POLE �, e FOR STRUCTURAL INTEGRITY. TOP OF FOUNDATION RAISE COVERS TO WITHIN ALC PIPE ro BE 4 in SCH 40 PVC EL = 50.63 +- b in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MIN 48.5 -00 MAX USE H-20 EMSTM 46.00 EXISTING 1500 GALLON °00000 o j„ o M,., PRECAST oga��84 �SCp�TOC� T�AI�IK 45.96 o p��pa o0o DRY W ELL in 45.35 ; EXISTING REFER TO DETAIL BOX STONE SM ABSORp�O N y 4,5.52 BASE 45.25 y 6 /n STONE AS IF NEW SYSTEM -REFER TO O EXISTING 19 ft 5-9 ft DETAIL BOX REPLACE WITH ANEW TWO NO GROUNDWATER BELOW COMPARTMENT 1500 GALLON 43.25 MOTTLING OBSERVED —37.10 TANK IF CRACKED. ROTTED OR OTHERWISE COMPROMISED: ROAD ���N OF 414. BAN OF MASS FALMOUTH ,DAVID ryG �P DAVID 9 SEWAGE DISPOSAL Route ZB ° D. D s� SYSTEM PLAN AMAR �,LOCUS u COUGHANOWR H y COUGHANOWR n -TO SERVE EXISTING DWELLING HIRRD v No. 1093 Na 461 " oP DENNIS C O N N O R S 79Sc� _ p •• �� OWNER(S) OF-RECORD NOT 'rcr 0 p0 ALUP TO JP��P I R E S Q 62-64 FRESH HOLES ROAD SCALE �� 0 !��5�°I PC ' 1 2�1 S 155; Geo Ryder Rd S HYANNIS y PROPERTY ADDRESS HYANNIS. MA THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM Chatham, MA 02633 DEPICTED ON IT.FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING DOVIdCOU@HOtmOILCOm GATE: NOVEMBER 6, 2018 PLACEMENT OF ADDITIONS. SHEDS,FENCES OR SWIMMING POOLS.OWNER L O C U S -M A P p(� :SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. SOH 3L4-0894 PG.1I2. JDB# ETE-4336 SOIL T E T d0 G ''. DEGION C A LC ULGA TI O NG SOIL EVALUATOR: DAVID D. COUGHANOWR, ASE #461 DESIGN FLOW: 4 BEDROOMS X 110 GPD = 440 GPD WITNESSED BY: DONALD DESMARAIS, HEALTH DEPT. SEPTIC TANK: 440 GPD X 2 DAYS = 880 GALLONS TEST PIT 1 NO GROUNDWATER ENCOUNTERED i USE EXISTING 1000 GALLON SEPTIC TANK /F IN PERC AT 50 in - 2 MIN/INCH IN C SOILS SOUND STRUCTURAL CONDITION. IF NOT, INSTALL ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER NEW 1500 GALLON SEPTIC TANK. INCHES HORIZON TEXTURE (MUNSELL) MOTTLES 48.10 0-8 FILL DISTRIBUTION BOX: INSTALL UNITY DEPICTED 8-12 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE SOIL ABSORBTION SYSTEM: 45.60 12-30 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 30-132 C MED-CSE SAND 10 YR 5/4 NONE LOOSE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES " 37.10 PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. NO GROUNDWATER ENCOUNTERED THE 'L' SHAPED LEACHING GALLERY TEST PIT 2 2 MIN/INCH IN C SOILS DEPICTED BELOW CAN LEACH: ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER BOTTOM AREA = (12.83 x (25+8.5) = 429.8 sq.. ft. INCHES HORIZON TEXTURE (MUNSELL) MOTTLES SIDEWALL AREA = 2x PERIMETER = 185.3 so. ft. 48.25 0-6 FILL TOTAL AREA = 615.1 sq. ft. 6-12 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE FLOW CAPACITY = 0.74 x 615.1 455.1 gal/day 45.58 12-32 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE 1 '32-132 C MED-(SE SAND 10 YR 5/4 NONE LOOSE INSTALL THE 'L" SHAPED LEACHING GALLERY AS CONFIGURED 37.25 BELOW. FLOW CAPACITY = 455.1 gol/doy WHICH EXCEEDS THE 440 goildoy REQUIRED FOR A FOUR BEDROOM DESIGN. 4_# 500 00 GALLON ME"M `TANK w allam laff r SuRcmalay Sam I YS /T[ 1(�]/ CONSTRUCTION DETAIL REPLACE WITH A NEW TWO USE SHOREY PRECAST 500 GALLON LEACHING DRYWELL COMPARTMENT 1500 GALLON DRYWELL 12.83 ft PERIMETER = l in TANK IF CRACKED, ROTTED OR OTHERWISE UNIT — 12.83 T A PER COMPROMISED. w +8.50 o +12.17 � Uo +12.83 12.17 f t +25.0 5 ft- o +21.33 ofcy) 8 in E =92.67 N ® co c4 c o TO 1Q ft_6 1 k� SCALE STONE 4 ft� 8.5 ft 8.5 ft 4 ft n 25 ft INLET OUTLET COVER COVER !' 500 GALLON DRYWELL -- DIMENSIONS & DETAIL INSTALL ONE INSPECTION 1 3 IN DROP —► /� FLOW LINE I 0 RISER TO WITHIN THREE FROM = USE INCHES OF FINAL GRADE 10 in 14 TO M-!0 & INDICATE LOCATION BUILDING 1� D-BOX UNIT ON AS-BUILT 48 in LIQUID GAS 33 In LEVEL BAFFLE - p 6 In STONE BASE 5$V, SEPARATION BETWEEN INLET & OUTLET 102 in TEES NO LESS THAN LIQUID DEPTH. ILCROSS SECTION VIEW CROSS SECTION VIEW _ _—__ INSTALL AN APPROVED GEOTEXTILE FABRIC OVER STONE 5O at 28 314 In TO. 0 24 in a 314 I t. 1-112 in GRAVEL EFFEi" VEa 1-112 in GRAVEL in z . .. o DEPTH D§S TG; O Lo) 40o nNl L) DB-3 H20 Uy fa 11 DIMENSIONS PIPES EXITING D-BOX TO RUN LEVEL 46 in 58 in 46 in AND DETAIL FOR 2 FEET BEFORE PITCHING DOWN I50 in ALL STONE TO BE DOUBLE WASHED AND FREE OF IRONS, DUST AND FINES IN PLACE - C MIN - -INSTALLER TO OBTAIN DISPOSAL WORKS II\VII PERMIT BEFORE STARTING WORK. FROM c. c N TANK „o TO -ALL COMPONENTS INSTALLED SHALL MEET SAS THE MINIMUM REQUIREMENTS OF Q ° MASSACHUSETTS TITLE 5 SEPTIC O CODE (310 CMR 15). -INSTALLER TO VERIFY LOCATIONS OF ALL \� 6 in STONE BASE UNDERGROUND UTILITIES BEFORE 21 in 2� CROSS SECTION VIEW T EXCAVATING FOR SYSTEM. -ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW lift PUMPING & APPLIANCES, AND PERIODIC. PUMPING OF THE SEPTIC TANK. -SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. SEWAGE DISPOSAL SYSTEM PLAN 62-64 FRESH HOLES ROAD HYANNIS, MA NOVEMBER 6, 2018 ETE-4336 PG 2/2 r Town of Barnstable Pit a Department of Regulatory Services ' c �►,warwLo. � Public Health Division Date r MAGI r,l 1,659. 200 Main Street,Hyannis MA 02601 �:1 rEn mil" �$• ' r Date Scheduled- Time / Fee Pd._ ;i/07 97 Soil Suitahility Assel!ssment for S ge Disposal co!f , Performed-By:(��L���t D qpa e, 4�I Witnessed By: t O LOCATION&.GENERAL INFORMATION Locatlon Address -• Fpe$h D jF S F j Owner's Name l'0 B h j S A N d IDS - Address - Assessor's Map/Parcel: 2_q Z^ V 7 _ Engineer's Name �k Vl/ 60✓0lL1li6-✓t^ NEW CONSTRUCTION REPAIR Telephone# �'O -364 05q Lnnd Use• V-e-1 1 eteutIL'1 f Slopes(96) Surface Stoncs '110ile Distances fl'om:• Open Water Body �(00 4 ft Possible Wet Area_L00 f ft Drinking Water Well ((�"f' ft Dtalhage Way K.l ft Property Line V + ft Other ft SIMTCH[(Street name,dimensions of lot,exact locations of test holes&Pero tests,locate wetlands-In proximlty to holes) LA � c p1 GNI. I'✓, Parent material(geologic) Pre� ov�r WC15 Depth to Dedroek d Depth to Oroundwater. Standing Water In Hole:- . Weeping from Pit Face 4917 C Estimated Seasonal High Groundwater - P2 'r(9G7 N 3 ! ►� DETERMINATION FOR SEASONAL-MGI1 WATER TABLE Method Used: V1141-4 1 h4 Depth Observed Stan ing in obs.hole: In. Depth to soil mottles: v c/f 3Z In.- . Depth to weeping from side of obs.hole: Ill. Groundwater Adjustment ft. Index Well- Rondingbato: lndox Well Imvel : AC-factor- Adj.Groundwatee•].evol,,,_ PERCOLATION TEST bate �1 Sly Time 10 A-0 Observation Hole 0 � Tinto at 4" �ZQ Depth of Pero .50 Time at 6" 05 Start Pro-soak Time 0 C9 ('✓ Timo(V-0) End Pre-soak - 6 0 Rate Mtn./Inch 2"!P I Site Suitability Assessment: Sito Passed SItp Palled: Additional Testing Necded(YIN) Original: Public Health Division Observution'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(I) week prior to beginning. Q:ISEPTICU'ERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole#_ I' Depth from Soli Horizon Soil Texture Still Color Soil. Other SurfaCe(in.) (USDA) (Munsell) Mottling (Stnucture,Stoned;Boulders, o isistency.%13rhyal) L. C6 - 12 A p Sq0 31e Q014P Ft ;01bl I`DIn P 10 516 ,, 13Z C .Ccr1se l®K l2�/ et Loose DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sol]Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. o I-tenov.To Orevel) IL L ----i —� — —� Q,'- 3Z, Gklq (p vp-S4 3z�: �`��. C �lc��C��� 1� ��- �� It Cats� • DEEP OBSERVATION HOLE.LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, f ti • DEEP OBSERVATION HOLE.LOG Hole# Depth from Soil Horizon Soil Texture Sall Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, Can r Flood Insumunce Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Dads at least four feet of naturally occurring pervious mtiterie exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what ig the depth of naturally occurring pervious matorlal9 Certificatt°n I certify that on NnV } (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consiste h . the requir in n expertis a d experience described In 10 CNM 15.017. cN OF Afq& S DateV�5, 20�g D/�VID Signature 10 D. " COQ, UA l OWR /�E N S�� pQ- Q:\SBpTILVERCPORM.DOC E VA IU P� I I h I i. Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 ,M 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name ! information is H annis MA 02601 1 1-25-10 required for y every page. City/Town State Zip Code i Date of Inspection Inspection results must be submitted on this form.Inspection forms'may not be altered in any way. A. General Information '{ , f 1. Inspector: �/ U i Shawn Mcelroy j Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr . Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number 1 i B. Certification I certify that I have personally inspected the sewage disposal system at this address and JN.at 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 ofron site sewage disposal systems. I am a DEP approved system inspector pursuant'to Sectior;15.340 of Title 5 (310 CMR 15.000).The system: • i ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Eva ation by the Local Approving Authority ` I 1-25-10 Inspector's Signature Date 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. ****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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 I Commonwealth of.Massachusetts Title 5 Offic.ia] Inspection "Form Subsurface Sewage Disposal System Form -Not for Voluntary'Assessments 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is Hyannis MA 02601 1-25-10,required for H y " every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by ,the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not, determined,"_please explain. ❑ 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 pipes) are replaced ❑ obstruction is removed t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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: ' 0 The system has aseptic tank and soil absorption system (SAS) and.the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent 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: . O. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6°below invert or available volume is less than 1/ day flow El ® 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . D) System Failure Criteria Applicable to All Systems (cont.): rf Yes No s, t ❑ ® 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. ❑ ® Any portion of a cesspool or privylis 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 15,00.0 gpd.. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D." Yes No ❑ ❑ the system is within 400feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary'to a surface drinking water supply El El Area system is located in .a nitrogen sensitive area (Interim,Wellhead Protection Area— IWPA)or a mapped Zone II of a public'water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E'or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for•Voluntary Assessments ,M 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes `No ° ,r ❑° �H, 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? ® ❑ 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? (If 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 ail^system components, excluding the SAS, located on site? ® ❑ 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 systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: . ❑ Existing information. For'example, a plan at the Board of Health. ® ❑, Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 l i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 1-25-10 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste hoidirig tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type 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 system owner) and a copy of latest inspection of the I/A.system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 t Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18" `feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by,a,Certificate of,Compliance? (attach a copy of certificate); ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500gal Sludge depth: 12 20" 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 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet 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: Date. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): t5insp official document.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 1 c , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions:, a Capacity: gallons Design Flow: gallons per day Alarm present: ❑. Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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 distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level. Pump Chamber(locate on site plan):' Pumps in working order: ❑ Yes . ❑ No Alarms in working order: ❑ "Yes ❑ No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'C 1M 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is Hyannis MA 02601 1-25-10 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System,(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5-infiltrators ❑ 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.): Infiltrators in good condition and empty at inspection with no sign of back-up into d-box or surrounding stone. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 ❑ 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 I Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp official document-03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is H annis MA 02601 1-25-10 required for y ' every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. Sri{ x . . f A.0 41. B-0-E hle le 5 OU t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62-64 Fresh Holes Rd Property Address Dennis Conners Owner Owner's Name information is required for Hyannis MA 02601 1-25-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope c ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' feet Please indicate all methods used to,determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® 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: Original design plans on file shows no groundwater at 12'. t t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 i YOU WISH TO OPEN A BUSINESS? OJIV2 For Your Information: Business.certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1' FL., 367 Main Street, Hyannis, MA..02601 [Town Hall) 07 uxx A Room.00 �A?' F ! i n GATE. A pleas$ /f� %/ J � r APPLIGANT'S YOUR NAME: C_ BfG- n � s u, BUSINES�S MI YOUR HOME ADDRESS. �z��i^i S Iti k i'IPS �-& n ' + t- —V t7 3 v ail. \ TELEPHONE # Ho Me Telephone Number NAME OF NEW BUSINESS TYPE OF BUSINESS i n IS THIS A HOME OCCUPATION? YE NO Have you Ifeen given approval from the building.di lion? YES 'NO ADDRESS OF BUSINESS 0 1:MAP/PARCEL NUMBER `. A , 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 thistown. ��.' 1. BUILDING COMMISSIONER'S OFFICE .w 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 been4fod o e pe requirements that pertain to this type of business. Authorinatur COMMENTS: . , S 3. CONSUMER AFFAIRS LICENSING AUTHOR Y) This individual h s en inf d of the nsi r ents that pertain to this type of business. Authorized Signature.* COMMENTS: N Hazardous Materials Inventory 5neet t;necKust !/ Date Physical Street Address-Check database to ensure it exists _ 4,,�Working Phone Number Actlyal Amounts-(le.gas being used to fuel machines,thinner to r clean brushes all count as hazardous materials) r �z r• / gage Information-location of storage,how long is storage for? —�� If none,note that. Disposal Information-where and who?If none,note that. 4-Z p�plicant Signature-understand what is listed and noted Staff Initial-any questions,know who to ask Vehicle Washing/Rinsing? -provide a vehicle washing policy and explain -note that it was given ZAttach the e Business Certificate with your sign off and comments "The inventory form should explain what the business consists of and the procedures Notes need to be left to explain what you discussed with them. Date: D�//�/Z�� TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: 162 re © e �` INVENTORY MAILING ADDRESS: zm4 TOTAL AMOUNT: TELEPHONE NUMBER: y' CONTACT PERSON: e EMERGENCY CONTACT TELEPHONE NUMBER: �7q 6- MSDS ON SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous,waste: Name of Hauler: �ZL Destination: Waste Product: &, n4- /,pAdn Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. j Observed/Maximum Observed/Maximum �.� Antifreeze (for gasoline or coolant systems) _ Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Lints, varnishes, stains, dyes�M I 6 r, / SlereW Other chlorinated hydrocarbons, -ga b s Lacpuer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint & varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers ��', L)5e-d x,- - C/ (including bleach) I h Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN OF BARNSTABLE 6 LOCATIONL2-4 6 Y SEWAGE # ��'« — Ll R D. VILLAGE /� na ASSESSOR'S MAP & LOT 9� - t 7-1_• INSTALLER'S NAME&PHONE NO. /77/h r,#0Q eP S&4 SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type) Z.v7-,- (size) .� NO.OF BEDROOMS ' BUILDER OR OWNER A�ilJl �►.t..y►-� PERMTTDATE: is 6U COMPLIANCE DATE: --1 L, - dr) 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 xF� ��.� �-�� _ - . PI .-1� ._# e �. ��_ � . —. —: �. . ^ �F: R �, .. (`V r r� '�[//�+ t ! � � � �" i v P it • •�• TOWN OF BARNSTABLE LOCATION (oa-1-- !64 Fi-95bf bk z-de K-A SEWAGE # VIE LAGE }��p ,.�� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Co►-�`ac r SEPTIC TANK CAPACITY �G LEACHING FACILITY:(type) r,4LL,&I (size) 4 X `f X Y NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER lV-154- C BUILDER O OWNER lGl-�Rrzh 94C C� DATE PERMIT ISSUED: �. DATE COMPLIANCE ISSUED: 7-- el VARIANCE GRANTED: Yes No a ON 1 • r No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for Oigponl *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System AIndividual Components Location Address or Lot No.�a—�� �- � Owner's Name,Address and Tel.No. Assessor's Map/Parcel a9 _`�� � —:7 rF I ya.,S Installer's Name,Addre`ssss,and Tel.No. Designer's Name,Address and Tel.No. M,0-GY�ee-SC-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 7 '1 L/ gallons per day. Calculated daily flow +(-/ gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank [ S7 e4 Type of S.A.S. C a i r (- Description of Soil A 2 Ss e_Sflut� Nature of Repairs,/or Alterations(Answer when applicable) _-X-6t-Srad 0—go-K- 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 Envir mental Code and not to place the system in operation until a Certifi- cate of Compliance has be issued by—this—Bo- d e 1 Signed Date Application Approved by Date a ^fib Application Disapproved for the follo ing reasons Permit No.20a�2 a �f 6 a- Date Issued I No. ' r'7 � Fee _ It; THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Ziopo.5ar *p!5tem Con!aructton Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) D Complete System Alridividual Components Location Address or Lot No.�a—(OQI 'Tt VU-0- kv Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. , 6AI ec Sc�el Type of Building: 2. Dwelling No.of Bedrooms-T Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons' " Showers( ) Cafeteria( ) Other Fixtures / Design Flow f`7,,`IrC/ gallons per day. Calculated daily flow ��f`� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank V 1, t 0?J t4 t C. Type of S.A.S. V4 cc, Description of Soils SeL cC> Nature of Repairs or Alterations(Answer when applicable) �V CAA-U-, 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 nmental Code and not to place the system in operation until a Certifi- cate of Compliance has b issued by this Bo d ealth Signed A Date Application Approved by Date LS�Gb Application Disapproved forte following reasons Permit No.Z 9L• Date Issued --�------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS y BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(k-10 Abandoned( )by I —C A E SF i at Vc A n %4-rL f has been constructed in accordance • with the provisions of Title 5 and the for Disposal System Construction Permit No.7,&2& VR a, dated Installer Designer The issuance of thi ertm shall not be construed as a guarantee that the system will function as designed. Date Inspector Lr --------------------------------------- No. 1 QDo- 2L Fee 'r7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ligpogai *p5tem Cott5tructton permit Permission is hereby granted to Construct( ) air( )Upgrade(C/�`Ab nd n System located at — �' �1 { j' 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:Construction must be completed within three years of the date of this permit. Date: Is-- /)d Approved by I 4- i 4� 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, 6 �` , hereby certify that the application for disposal works construction permit signed by me dated �`�`� , concerning the property located at ��—� A'C2 }� meets all of the following criteria: V- This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. u 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 v here 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 ap able] • 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: ' I g� A) Top of Ground Surface Elevation(using GIS information) y 0 �O B) G.W.Elevation (2✓l/+the MAX. High G.W.Adjustment.ai_T= -c?-7 DIFFERENCE BETWEEN nd B SIGNED : DATE: [Please Sketch prop sed plan of system 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. q:health folder:cert TOWN OF BARNSTABLE • L LOCATION 4 C/t'tyH hid SEWAGE i1 R `7 VII LAGE i ASSESSOR'S MAP & LOT : - - I LJ-- INSTALLER'S-NAME&PHONE NO. M 16 Hn SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ;"►/ r;7 (size) S NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: `Y 'l� -�c> 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by T- ' R Commonwealth of Massachusetts AL Executive Office of Environmental Affairs RECEOVED Department of JAN 4 1995 Environmental Protection . HEALTH oEPT TOWN OF BARNSTABLE Wllllam F.Weld e vemor Trudy Coxe Secretary,EOEA David S.Struhs Commissioner SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . In C_ CERTIFICATION Property Address: Address of Owner: Date of Inspection: �� �°a (If different) Name of Inspector: W.E. Robinson Sr. Company Name, Address and Telephone Number: W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT --7 77�77 I certify that I have personally inspected the sewage dispos l s�s(ert%t this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewa a disposal systems. The system: _ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails n y Inspector's Signature: !iv t t y Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D` AJ SYSTE PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. .B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or Nb). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with.a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)SWI049 • Telephone(617)M-5500 40 Printed on Recycled Paper t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION (continued) Property Address: (o �'y /:r e.S�7 h14)le- �,P o���l/1 S 3 Owner: m Date of Inspection: 1,2 Z`�—g,S" B] SYSTEM CO ITIONALLY PASSES (continued) -Se age backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pi (s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Boar of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The syst m required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspecti n if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATI N IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist hich require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safe and the environment. 1) SYSTEM WILL PA UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PR TECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspo or privy is within 50 feet of a surface water Cessp of or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM LL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The syste has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface wa r supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The systen has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply we I, unless a well water analysis 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. D) SYSTEM FAILS: I have determined th the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of wage into facility or system component due to an overloaded or dogged SAS or cesspool. _ Discha a or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspo (revised 8/15/95) 2 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: °� �� 6 Al A�x4h /I/S Owner: n-1 G C a-// Date of Inspection: ` �1 7 % DJ SYSTE ILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion.of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen-and nitrate nitrogen. E] LARGE SY TEM FAILS: e following criteria apply to large systems in addition to the criteria above: The esign flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and t e environment because one or more of the following conditions exist: 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 II of a public water supply well) The owner or o rator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 14 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 3 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST �d2 �'y /�/e�Slt Lfo��f�•� �j��z11�� Property Address: Owner: Date of Inspection: ;- gam Check if the fZpumping llowing have been done: information was requested of the owner, occupant, and Board of Health. JL1 one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. -'As built plans have been obtained and examined. Note if they are not available with N/A. he facility or dwelling was inspected for signs of sewage back-up. '/the system does.not receive non-sanitary or industrial waste flow l/the site was inspected for signs of breakout. —4/1I.system components, excluding the Soil Absorption System, have been located on the site. �he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. 1/fhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. I (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: y ��Q S h �6/t /� ,1��/g�y►vt r,f Owner: Date of Inspection: l -A7 `lam FLOW CONDITIONS RESIDENTIAL: Design flow: � ` Q Ilons Number of bedrooms: Number of current residents:. Garbage grinder (yes or no):—t/ Laundry connected to system (yes or no):� Seasonal use (yes or no):� Water meter readings, if available:111/A Last date of occupancy: 1 --aq-5 S— COMMERCIAUINDUSTRIAL• Type of blishment: Design flow: allons/day Grease trap pr ent: (yes or no)_ Industrial Wast Holding Tank present: (yes or no)_ Non-sanitary wa to discharged to the Title 5 system: (yes or no)_ Water meter rea ings, if available: Last date of occ panty: OTHER: (Desc ibe) Last date of o cupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: V S System pumped as part of inspection: (yes or no)_ If yes, volume pumped. gallons Reason for pumping: TYPE OF STEM 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: �ci >t�v—titJ Sewage odors detected when arriving at the site: (yes or no)f z (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: Zete _metal _FRP other(explain) Dimensions: 'r Sludge depth: It) Distance from top of sludge to bottom of outlet tee or baffle:,R 15- Scum thickness: G , Distance from top of scum to top of outlet tee or baffle: S , Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 11g-O / So o o/ T a ti,x A, -w >7 '7 �s— GREAS RAP:_ (locate on 'te plan) Depth below rade: Material of con truction: _concrete _metal _FRP—other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bolt m !N «um tM hotfom of 006et tee or baffle: Comments: (recommendation f r pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence f leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C yy SYSTEM INFORMATION (continued) Property Address: Ua� :, 'y /'/'2.5A i-la/e Owner: k mac, Ca-!! Date of Inspection: TIGHT O OLDING TANK:_ (locate on site Ian) Depth below gra Material of constru ion: _concrete _metal _FRP—other(explain) Dimensions: Capacity: _gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet t e, condition of alarm and float switches, etc.) DISTRIBUTION BOX._ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carr)-over, evidence of leakage into or out of box, etc.) 0 PUMP CH)AR (locate on Pumps in der.(yes or no) Comment(note conmp chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Fre�Sh Wole AO �y�gnn"S Owner: IZ , YPI C, c o-/ Date of Inspection: Ig �, 9� SOIL ABSORPTION SYSTEM(SAS): Z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ t � leaching galleries, number: �f 1 S 1 c rt-t: Ip Ac- leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPO (locate on site Ian) Number and con uration: Depth-top of liqui to inlet invert: Depth of solids lay r. Depth of scum laye Dimensions of cessp ol: Materials of constru ion: Indication of ground ater. inflow (cess ool must be pumped as part of inspection) Comments: (note)dition 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 condit' nA�soil, ns of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C c SYSTEM INFORMATION (continued)) , Property Address: ` T�.e �l L�D/C /�Q x-ly�I?/11 S Owner: Date of Inspection: _ 9 5 Z i SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' k Ito G c ` . f nc s �( f-1© 1L✓ � DEPTH TO GROUNDWATER Depth to groundwater: I � feet — 'J 1, method of determination or approximation: l O fl0/i-s l CZ G`ll+"S. /�4� o (revised 8/15/95) 9 �y C SENDER: Complete items 1,2,and 3. !� o Add your address in the"RETURN TO"space on 3 reverse. ' w I. The follow;,n�service is requested (check one). -/q Show to whom and date delivered. . . .. .. .. .¢ Show to whom,date,and address.of delivery. ._¢ RESTRICTED DELIVERY Show to whom and date delivered. .. .. .... . RESTRICTED DELIVERY. Show to whom,date,and address of delivery.$_ (CONSULT POSTMASTER FOR FEES) 2. ARTICLE ADDRESSED TO: M Elizabeth C.Jbnes,Trustee, Quaker Village Assn. , c/o"•bollzen c Inc. ,Agents-40 Court St. BOS ON. Z 3. ARTICLE DESCRIPTION: 210E z n REGISTERED NO. CERTIFIED NO INSURED NO. 0019811 1 m I (Always obtain signature of addressee or agent) 2 I have received the article described above. m SIGNATURE ❑ Addressee ❑ Authorized agent z m o y4 C DAT OF DELIVERy� f' "1POSTIW* m Zz5. ADDRESS (Complete only if requested) m 3 6. UNABLE TO DELIVER BECAUSE: ` �CpE S O �...f � IALS 3 D i GPO: 1978-272-382 I UNITED STATES POSTAL SERVICE OFFICIAL BUSINESS SENDER INSTRUCTIONS PENALTY FOR PRIVATE q USE TO AVOID PAYMENT Print your name,address,and ZIP Code in the space below.Complete items 1,2,and 3 on the reverse. OF POSTAGE,$300 • Attach to front of article if space permits.Otherwise LLS.MAIL �i affix to back of article. �O • Endorse article"Return Receipt Requested"adja- cent to number.. RETURN P: TO N BOARD OF HEALTH (Name of Sender) TOWN OF BARNSTABLE E P_ O. Box 534 (Street or P.O. Box) HYANNIS MA 02601 (City,State,and ZIP Code) y G SENDER: Complete items 1,2,and 3. Add your address in the"RETURN TO"space on 3 reverse.' 1. The following service is requested (check one). Show to whom and date delivered. . . .. .. .. . ❑ Show to whom,date,and address of delivery. ._¢ RESTRICTED DELIVERY Show to whom and date delivered. .. .. . . .. ._¢ RESTRICTED DELIVERY. Show to whom,date,and address of delivery.$_ (CONSULT POSTMASTER FOR FEES) 2. ARTICLE ADDRESSED TO: (� Elizabeth C.Jones,Trus-tee M Quaker Village Assn. ,c/o Dolb n m c Inc. ,Agts. ,40 Court St. ,Bost n Z 3. ARTICLE DESCRIPTION: as—s 108 z n REGISTERED NO. CERTIFIED NO. INSURED NO. I0019810 z I (Always obtain signature of addressee or agent) m 2 I have received the article described above. m SIGNATURE ❑ Addressee Authorized agent 33 v r y 4. C DA E F DELIVER RK 2 5. ADDRESS (Complete only it reque led 0 50 m T 6. UNABLE TO DELIVER BECAUSE: \ 9wes � 3 D GPO: 1978-272-382 UNITED STATES POSTAL SERVICE OFFICIAL BUSINESS SENDER INSTRUCTIONS USE FOR PRIVATE 1 F our name,addre and ZIP Code in the space below. SE TO AVOID PAYMENT OF POSTAGE, $300 y.>, Complete items 1,,2,and 3 on the reverse.Attach to front of artiole_if space permits.Otherwise LL&MAIL Paffix-to back of article , O Endorse article"Retureceipt Requested"adja- cent to number. (y RETURN TO BOARD OF HEALTH TOWN OFNaBARNSTABLE P. 0. Box 534 (Street or P.O. Box) HYANNI5 MA 02601 (City.State.and Z111 Code) v 11pril' 29. 1981 Eli abeth C. Jones, Trustee- Quaker Village;Assn.y c/o. Dolben Xnc. ,Agents " .; 40 Court: Street Boston, 4Ma". 021Q8, K NOTICE TO 'ABATE APUBLZC HEALTH. NUISANCE s Property.°owned by `ydu at 62. Fresh Holes Road; Hyannis, 'ways Fin- . spected 'on April 27, 1981,,-by Ronald "G3ford, Health Inspector -for 'the` Town =of. -Barnstable; because of a complaint by the tenant, Michelle Gifford. The following vioi­ations,,of State Sanitary Code, Chapter: TZ, 105' CMR". 410.000 were foundz - " - REGULATION 410:150, (D) : Deteriorating caulking' at ndM wail, making :cleaning difficult srtd allowing mold buildup, ' REGULATION. 410, 500:• ; Peeling pant on bathroom and living room caalls. Hole n wall ny`bathroam. by tub. e; Door casing-: loose 6n', 4 D' front do_ or. ,. REGULATION 410. 311 'Electrical outlet in`;rear `(green)' bedto s inoperable, Sw tchplate-,missing :in.' rear *be'oom. REGHLAT'ION 41055 3:- Screens. torn an-both front and 'rear •doors and front tan) bedroom. , wer''at �itehenREGULATION 410.` 9Tnsuffidid 't hot . at sink -� F 85 =degrees F.' -, must be mini ►um of',1:2'0 degrees F. Regulation` 4].0.190 is listed uncer�'Regulat3.on 410.750 (A) asA. ,condition;which may `endanger or. impair the .health; :or safety. .and.` ��;;� >�wellbeing of :the. person ,occupying the premises. 1:You. 'are'.directedb ' to. correct this violation-`within' twenty -four (24) ,hours of rece� t' - LL of this. notice: -You- are 'directed 'to correct all o'they viol ations" within -fiv' a '(5) days '`after the receipt of;, th�i's order. �. Elizabeth C. Jones • Trustee Page 2 April 29. 1981 s' t -.You may .request; a hearing before ;the Board' of.'H®aTtYi $f' written ` petition •requesting, same -is received seven (7)„j days; after the date -order. served. m Non-compliance could result 'in .a ne of- up to "$500. EacY}°day's failure to comply with., an order shall ,constitute a.-separate; i violatiori. PER. 6HRDR'-OF THE''BOARD OF HEALTH r John M. Kelly. Director of Public .Health.eIN s ' ' Ji4l`/Ll4U ' cc: Ms. Michelle Gifford Mr. Grover Martin a e„ f 1 . BOARD OF HEALTH. . . { Town of Barnstable P.O. Box 534 Hyannis, Massachusetts 02601 ti This is an important legal document. It may affect your rights. You may "obtain a translation of this form at the Town Office. ARTICLE II STATE SANITARY CODE Address: . . . . . .6�7 0 . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . No. Occupants . . . . . . . . . . . . Occupant: . . . . I./ .j\,l. . . . .C'-; D. . . . . . Floor; . . . . . . . . Apt. No. . . . . . . . . No. Dwelling Units: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. Rooming Units: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. Stories: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basement: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Type Structure: . . . . . . . . . . . . Frame: . . . . . . . . . . . . Brick: . . . . . . . . . . . . Semidetached: . . . . . . . .I . . . . Detached: . . . . . . . . . . . . No. of Habitable Rooms: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. of Sleeping Rooms: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Owner: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . . . X=VIOLATIONS REGULATION LIVING ROOM YES NO 7.1(a) Is there sufficient natural light? 7.1(b) Are there two separate electrical outlets in good repair? 7.1(b) Is there one outlet and one' light fixture in good repair? 8.1A,8.1B(e) Is there proper ventilation? 13.1A Are the windows in good repair, weathertight and fit for the use intended? X_ 13.1 Are the walls in good repair and fit for the use intended? 13.1 Are the ceilings in good repair and fit for the use intended? p p 13.1 Are the floors in good repair and fit for the use intended? _ 14.5 Are the exterior openings screened? REGULATION SLEEPING ROOM #1 (identify) �- 7.1(a) Is there sufficient natural light? 7.1(b) Are there two separate electrical outlets in good repair? 7.1(b) Is there one outlet and-.one light fixture in good repair? 8.1 A,8.1B(e) Is there proper ventilation? 13.1A Are the windows in good repair, weathertight and fit for the use intended? 13.1 Are the walls in good repair and fit for the use intended? 13.1 Are the ceilings in good repair and fit for the use intended? 13.1 Are the floors in good repair and fit for the use intended? 14.5 Are all exterior openings screened? 11 Is there adequate space for the number of occupants? ' V7 Y REGULATION SLEEPING ROOM #2 (identify) 7.1 (a) Is there sufficient natural light? r ro 7.1 (b) Are there two separate electrical outlets in good repair? At-A, F�- 7.1 (b) Is there one outlet and one light fixture in good repair? �-� ✓ 8.1 A, 8.1 B(e) Is there proper ventilation? ' 13.1 A Are the windows in good repair, weathertight and fit for the use intended? _ 13.1 Are the walls in good repair and fit for the use intended? 13.1 Are the ceilings in good repair and fit for the use intended? 13.1 Are the floors in good repair and fit for the use intended? 14.5 Are all exterior openings screened? 11 Is there adequate space for the number of occupants? REGULATION BATHROOM 3.1A(a)3.1B(a) Is-toilet with seat available? 11A(b)3.1B(b) Is washbasin available? ( `;A 3.1A(c)3.10(c) Is shower or bathtub available? s� °J u" 3.1D 3.2 Are the facilities in a clean, smooth, impervious and sanitary condition? ,/,7 4.1 (9.1 &9.2). Is cold water for facilities available (with sufficient quantity)? 5.1 (9.1 &9.2) Is hot water for.facilities available (120 F- 140 F)? 9.1 &9.2 Are the facilities properly connected to drain line? 7.3&9.3 Is there at least one light fixture in good repair? 7..4.& 9.3 Is there an electrical outlet in good repair at washbasin? 13.1 & 13.1A Are the windows in good repair, weathertight and fit for the use intended 13.1 Are the doors in good repair and fit for the use intended? 13.1 &13.6 Are the walls in good repair and fit for the use intended? 13.1 & 13.6 Are the floors in good repair and fit for the use intended? 8.1A&8.1B Is there proper ventilation? 13.6 Are the floors and walls of nonabsorbent material? 14.5 Are the exterior openings properly screened? L. X-VIOLATIONS 'REGULATIJN KITCHEN t` ;° YES NO 2.1 Is the room suitable? _2.1(a) s Is the sink available and of sufficient size and capacity? 4.1(9.1 &9.2) , Is cold water for the sink available (with sufficient quantity and pressure)? 5.1(9.1 &9.2) Is hot water for sink available (120 F- 140 F)? O'er 9.1 &9.2 Is sink properly connected to drain lines? 2.1(b) Is there a working stove and oven? 9.3 Is the stove and oven properly connected and vented? 2.2 Are the facilities clean, smooth,.impervious, nonabsorbent? 7.2(a) Is there one light fixture in good repair? 7.2(b) Are there`two electrical outlets in good repair? 7.2(c) Are the windows (if kitchen exceeds 70 sq.ft.)equal to at least 10% of the floor area? _13.1 & 13.1A Are the windows in good, repair, weathertight and fit for the use intended? 14.5 Are the exterior openings properly screened? 13.1 Are the doors in good repair and fit for the use intended? 13.1 Are the walls in good repair and fit for the use intended? 13.1 Are the ceilings in good repair and fit for the use intended? 13.1 Are the floors in good repair and fit for the use intended? 13.6' Is the floor impervious and easily cleanable? 2.1(c) Is there adequate space and facilities for installing of Refrigerator? 8.1A,8.1B(a) Is there sufficient ventilation? 9.3(a)9.3(b) Are all owner installed appliances properly installed? 9:4 Are all occupant installed appliances properly installed? REGULATIONS COMMON AREA AND EXITS 7.5 Are interior common areas properly illuminated at all times? 7.7 Are there operational and sufficient and properly located light switches and fixtures? 13.1A Are the windows in good repair, weathertight and fit for the use intended? 13.1E Are the doors in good repair, weathertight and fit for the use intended? 14.5 Are all doors screened as required? , 13.1 Are the ceilings in good repair and fit for the use intended?,., 13.1 Are the walls in good repair and fit for the use intended? 13.1 Are the floors in good repair and fit for the use intended? 15.8& 15.9 Are all common areas clean? 13.1 Are the stairways in good repair and fit for the use intended? 13.3& 13.4 Are handrails in good repair and fit for the use intended? 13.5 Are all required balusters or other devices in place? 18.4 Is every entry door of a.dwelling unit fitted with a prop_er lock? 18.3 Does the main entry door of a dwelling close and lock automatically? 18.6 Is the building properly posted with the name of owner? 3.2 Are the common bathroom facilities clean? 12.1 & 12.2 Are there sufficient and properly maintained exits? ' REGULATIONS EXTERIOR Are light fixtures and switches properly located? 13.1 Is the chimney in good repair? ; 13.1 Are the porches in good repair? 13.1 Is the foundation in good repair? 13.1 Are the stairs in good repair? 13.1 Are the structural elements in good repair?- 13.3, 13.4& 13.5 Are all required .hand railings and balusters in place and in good re air? 13.4 Are there walls or protective railings as required? 15.4 Is the storage of rubbish and garbage proper (occupants)? _15.3 Are there sufficient and properly located receptacles? 15.10 Are the private passageways or rights of way clean and sanitary? 13.1 Are the gutters and down spouts in good repair and`fit for the use intended? REGULATIONS GENERAL 10.1 Are all required services available and working? 6.1 Are the heating facilities in good repair? 6.2 Is heat being supplied at proper temperatures. (68 F-78 F)? 5.1 Are hot water heating facilities in good "repair? 9.3(a) Are all required facilities properly installed and vented? 6.5 All space heaters in use meet the proper requirements? 7.9 Is there no temporary wiring in use? Location? 7.8 Is the electrical service safe and adequate? 14.1, 14.2& 14.3 The dwelling is free of insect/rodent presence? 15.7 Is the dwelling unit maintained in a clean and sanitary condition by the occupants? REGULATION OTHER <� 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,byyRegulation 29.2 of the code or the AuthorizedInspector.� A.M. INSPECTOR TITLE A.M. P.M. DATE TIME THE NEXT SCHEDULED REINSPECTION IS: DATE TIME 7HEj TOWN OF BARNSTABLECapy �O Oky Q OFFICE OF BAH MASS. : BOARD OF HEALTH . y MASS. of OOA i639- � 367 MAIN STREET MA'S HYANNIS, MASS. 02601 April 29, Elizabeth C. Jones, Trustee Quaker Village Assn. c/o Dolben Inc. ,Agents 40 Court Street Boston, Ma. 02108 NOTICE TO ABATE A PUBLIC HEALTH NUISANCE The property owned by you at 33 Fresh Holes Road, Hyannis, was in- spected on April 21, 1981, by Ronald Gifford, Health Inspector for the Town of Barnstable, because of a complaint by the tenant, Evelyn Mendoza. The following violations -of State Sanitary Code, Chapter II, 105 CMR 410.000 were found: REGULATION 410.150 (D) : Deteriorating caulking along bathtub and wall making cleaning difficult and allowing mold buildup. REGULATION 410. 351 : Electrical outlet it. Lying room along dividing wall of apartment inoperable. Front porch light inoperable. REGULATION 410. 553: Screen on front bedroom window torn and screen on rear door torn. You are directed to correct the above violations within five (5) days of receipt of this notice. You may request a hearing before the Board of Health if written petition requesting same is received seven (7) days after the date order served. Non-compliance could result in a fine of up to $500. Each day' s failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH ;-n hn M. Keilyrector of P is Health JMK/mm cc: Mr. Grover Martin Ms. Evelyn Mendoza a�r �, • � r � �� � �: . ..��° BOARD OF HEALTH' i d Town of Barnstable P.O. Box 534 Hyannis, Massachusetts 02601 This is an important legal document. It may affect your rights. You may obtain a translation of this form at the Town Office. ARTICLE II STATE SANITARY CODE Address: . . . . . -�. . . . . . C� ESy. . . . .} O.6 .5 . . .2 . . . . . .1✓}A n/.N/.5 . . . . . . . . . No. Occupants . . . . . . . . . . . . Occupant: . . . . . . .��-`.1/c`G1!1I . . . . . . � E/y.1�dZ. . . . . . . . . . . Floor. . . . . . . . . Apt. No. . . . . . . . . 1 No. Dwelling Units: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. Rooming Units: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. Stories: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basement: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ;i Type Structure: . . . . . ... . . . . . Frame: . . . . . . . . . . . . Brick: . . . . . . . . . . . . Semidetached: . . . . . . . ., . . . . Detached: . . . . . . . . . . . . No. of Habitable Rooms: . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . No. of Sleeping Rooms: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Owner: Address: . . . .'. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X=VIOLATIONS REGULATION LIVING ROOM YES NO 7.1(a) Is there sufficient natural light? 7.1(b) Are there two separate electrical outlets in good repair? 7.1(b) Is there one outlet and one light fixture in good repair? �-�y,A� 8.1A,8.1B(e) Is there proper ventilation? 13.1A Are the windows in good repair, weathertight and fit for the use intended? 13.1 Are the walls in good repair and fit for the use intended? 13.1 Are the ceilings in good repair and fit for the use intended? 13.1 Are the floors in good repair and fit for the use intended? 14.5 Are the exterior openings screened? �l REGULATION SLEEPING ROOM #1 (identify) ���✓ .� / 7.1(a) Is there sufficient natural light? 7.1(b) Are there two separate electrical outleirs in good repair? 7.1(b) Is there one outlet and one light fixture in good repair? 8.1 A,8.1B(e) Is there proper ventilation? 13.1A Are the windows in good repair,-weathertight and fit for the use intended? 13.1 Are the walls in good repair and fit for the use intended? 13.1 Are the ceilings in good repair and fit for the use intended? 13.1 Are the floors in good repair and fit for the use intended? 14.5 Are all exterior openings screened? Y,, L 11 Is there adequate space for the number of occupants? REGULATION SLEEPING ROOM #2 (identify) 7.1 (a) Is there sufficient natural light? 7.1 (b) Are there two separate electrical outlets in good repair? 7.1 (b) Is there one outlet and one light fixture in good repair? 8.1 A, 8.1 B(e) Is there proper ventilation? 13.1 A Are the windows in good repair, weathertight and fit for the use intended? 13.1 Are the walls in good repair and fit for the use intended? 13.1 Are the ceilings in good repair and fit for the use intended? 13.1 Are the floors in good repair and fit for the use intended? 14.5 Are all exterior openings screened? 11 Is there adequate space for the number of occupants? REGULATION BATHROOM 3.1AM 3.1B(o) Is toilet with seat available? 3.1A(b)3.1B(b) Is washbasin available? 3.1A(c)3.1B(c) Is shower or bathtub available? 3.1D 3.2 Are the facilities in a clean, smooth, impervious and sanitary condition? n/ 4.1 (9.1 &9.2). Is cold water for facilities available (with sufficient quantity)? 5.1 (9.1 &9.2) Is hot water for.facilities available (120 F- 140 F)? 9.1 &9.2 Are the facilities properly connected to drain line? 7.3&9:3 Is there at least one light fixture in good repair? 7.41 r3i 9.3 Is there an electrical outlet in good repair at washbasin? r 13.1 & 13.1A Are the windows in good repair, weathertight and fit for the use intended? 13.1 Are the doors in good repair and fit for the use intended? 13.1 & 13.6 Are the walls in good repair and fit for the use intended? 13.1 & 13.6 Are the floors in good repair and fit for the use intended? 8.1A&8.113 Is there proper ventilation? ;^ 13.6 Are the floors and walls of nonabsorbent material? 14.5 Are the exterior openings properly screened? X=VIOLATIONS REGULATION KITCHEN YES NO Is the room suitable?' 2.1(a) Is the sink available and of sufficient size and capacity? 4.1(9.1 &9.2) Is cold water for the sink available (with sufficient quantity and pressure)? 5.1(9.1 &9.2) Is hot water for sink available (120 F- 140 F)? 9.1 &9.2 Is sink properly connected to drain lines? 2.1(b) Is there a working stove and oven? 9.3 Is the stove and oven properly connected and vented? 2.2 Are the facilities clean, smooth, impervious, nonabsorbent? 7.2(a) Is there one light fixture in good repair? 7.2(b) Are there two electrical outlets in good repair? 7.2(c) Are the windows(if kitchen exceeds 70 sq.ft.)equal to at least 10% of the floor area? 13.1 & 13.1A Are the windows in good repair, weathertight and fit for the use intended? 14.5 Are the exterior openings properly screened? 13.1 Are the doors in good repair and fit for the use intended? 13.1 Are the walls in good repair and fit for the use intended? 13.1 Are the ceilings in good repair and fit for the use intended? 13.1 Are the floors in good repair and fit for the use intended? 13.6 Is the floor impervious and easily cleanable? 2.1(c) Is there adequate space and facilities for installing of Refrigerator? 8.1A,8.1B(a) Is there sufficient ventilation? 9.3(a)9.3(b) Are all owner installed appliances properly installed? 9.4 Are all occupant installed appliances properly installed? REGULATIONS COMMON AREA AND EXITS 7.5 Are interior common areas properly illuminated at all times? 7.7 Are there operational and sufficient and properly located light switches and fixtures? 13.1A Are the windows in good repair, weathertight and fit for the use intended? 13.1 E Are the doors in good repair, weathertight and fit for the use intended? 14.5 Are all doors screened as required? 13.1 Are the ceilings in good repair and fit for the use intended? ' v - 13.1 Are the walls in good repair and fit for the use intended? 13.1 Are the floors in good repair and fit for the use intended? 15.8& 15.9 Are all common areas clean? 13.1 Are the stairways in good repair and fit for the use intended? 13.3& 13.4 Are handrails in good repair and fit for the use intended? 13.5 Are all required balusters or other devices in place? 18.4 Is every entry door of a dwelling unit fitted with a proper lock? t 18.3 Does the main entry door of a dwelling close and lock automatically? 18.6 Is the building properly posted with the name of owner? 3.2 _ Are the common bathroom facilities clean? 02.1 & 12.2 Are there sufficient and properly maintained exits? REGULATIONS EXTERIOR e Are light fixtures and switches properly located? 13.1 Is the chimney in good repair? v r 13.1 Are the porches in good repair? 13.1 Is the foundation in good repair? 13.1 Are the stairs in good repair? 13.1 Are the structural elements in good repair? 13.3, 13.4& 13.5 Are all required and railings and balusters in place and in good repair? 13.4 Are there walls or protective railings as required? 15.4 Is the storage of rubbish and garbage proper (occupants)? 15.3 Are there sufficient and properly located receptacles? 15.10 Are the private passageways or rights of way clean and sanitary? 13.1 Are the gutters and down spouts in good repair and fit for the use intended? REGULATIONS GENERAL 10.1 Are all required services available and working? 6.1 Are the heating facilities in good repair? 6.2 Is heat being supplied at proper temperatures. (68 F-78 F)? 5.1 Are hot water heating facilities in good repair? 9.3(a) Are all required facilities properly installed and vented? 6.5 All space heaters in use meet the proper requirements? 7.9 Is there no temporary wiring in use? Location? 7.8 Is the electrical service safe and adequate? 14.1, 14.2& 14.3 The dwelling is free of insect.rodent presence? 15.7 Is the dwelling unit maintained in a clean and sanitary condition by the occupants? uGS REGULATION OTHER 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 Regulation 29.2 of the code or the Authorized Inspeec/tor.. A.M. p f.M. CNSPECTUR y TITLE A.M. DATE `� '' TIME THE NEXT SCHEDULED REINSPECTION IS: DATE TIME ' THE COMMONWEALTH OF MASSACHUSETTS "Vl""Fnim..................v........ BOAR® OF HEALTH TOWN OF BARNSTABLE lira Jisposal Works Tomitrurti oru Prrutit A on is hereby ma e fo a ermit to Construct ( ) or Repair (t)an Individual Sewage Disposal System at• ..............1 1114 . ....ems.. .,-u... .. 92� ........= ..4 ����---- o dress or Lot No wne Address Installer Address d Type of Building Size Lot............................Sq. feet U DwellingNo. of Bedrooms.............................. _.___Ex Expansion Attic— --------- p ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers W g -•------•-•----•------------ P ( ) — Cafeteria ( ) Otherfixtures ---------------------------------•----------------•-----•----•-----------••-••----•--------•---•-•-....--------------•-• ----.•---- 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 tank ( ) 1­4 Percolation Test Results Performed by.......................................................................... Date........................................ 1 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit...:................ Depth to ground water........................ 9 -... •----------------------------------------------------------------------------------------------- ---------------- ---------------- ...... ---------------- --- O Description of Soil...............................................................................------------------------------------•--------------------------------------------------- x c., w U Nature of Repairs or Alterations—Answer when applicable.,/J'� ...... ....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental —The undersigned further agrees not to place the system in operation until a Certificate of Compliance W Wn issued by Mor4 of health. Signed - ........ ............ . e ------------�-------------- Date �c Application Approved By --.... = . ...... ........... ......" .. .....' ........ -- . .....---.'�L�"' ' .............'-----------...... Date--....... .-'-- Application Disapproved for the following reasons- ---------..................................................----------------------- ------------------------------- --............... .................................................................. ------. . . ' to Permit115 No. ....J , ............. Issued .------ ..:. 'ram - ...... Date THE COMMONWEALTH OF MASSACHUSETTS VI" Fizz BOARD OF HEALTH ��- TOWN OF BARNSTABLE �-�� ��lirtt��>��f - r �i��la��a1 •�rk,� C�•����x�s�inn .r�mt# Application is hereby made for a Permit to Construct ( ) or Repair (/an Individual Sewage Disposal System at � • Loc o Address �f or Lot N. /!/ �/�fyliii d �7i� ................_..... .... .. �21 ----- .../ ... ...- �. .. ... �.�._.... Owne.r _ Address a -•. ................................................................ / ..:----.. � .--�`.!1 f ��CR._...��...�l�C�.���,n� Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..............!-_..........__...._..._...Expansion Attic ( ) Garbage Grinder ( ) � Other—T e of Building g ----------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------•-----....-----------------------------•---•-----•-•--------------.._...--•-•••-•--•-•-----•----------........--------............. W Design Flow............................................gallons per person pet 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 tank ( ) aPercolation Test Results Performed by ----------------------------------•--------------- Date Test Pit No. I................minutes per inch Depth of Test Pit...........__....... Depth to ground water........................ rz Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••-•-•-•--••----------------•---••-•--•------••--------•--------•--•----------•-••-------•----...---..................................... ----...--•---•-•-- 0 Description of Soil................................................................................................................. ----------------------------------.................... W V ....-----•---------•---••-••---•----------••---------•---•---------------••--••-••-------------•-•-•--•---•----------------••-•-------•--••-•----••----••-•---------=-----•--•--•---...-•---•-•--•-••-- W - - x -•--••----------------------••...----------••---••--•-----------•----••••--••----------------•••-----------------------•--------------•---•--••-----•---•---•-•-•-----•-•-•-•-••-••------------..-•---- U Nature of Repairs or Alterations—Answer when applicable.-- 5f.....1. F'_�y/.l!a! �____... . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code?—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has e n issued by toe board of health. Signed ........................................ .......... ...-.........-... --------- .....• Dale �e Application Approved BY - -- -------- ----------- ------ ........................ Irate Application Disapproved for the following reasons- ------------------ ---- ----------------- --------- --- --------------------------- --- -------------------------- --- - ---- ---------------- ---- -.....-....--------------------------.......---.....---------------------------------------------------...----------------------------- ------------------------------------ Date Permit No. Issued .............. -.....---------------.....---------- Date THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH TOWN OF BARNSTABLE Certtfirate of Tompliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( V ) by.. G= l/. ....� :5 4"--� _s.....`." �---I---------------------------- -----------------.................................... Installer -------------------------------- ...............................------------------------------------------------ has been installed in accordance with the provisions of TITLEA of The State Environmental Code as describedin the application for Disposal Works Construction Permit No. .� � .. / pp dated a p `� , .. �1------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE = ..' ...... --------------------------- Inspector ..-------- .... 1--..� :-... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �f TOWN OF BARNSTABLE �0 o� FEE....................... Permission is hereby granted...... ---- .� a 5 ,�:. _"4'-`_----..- =` .......................................... - -- = 0--= ------ \ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No C�-�- `'1----�.�--.'��--'P--S--�------L��?�-�-------- �----�-- �- -I'±'�?.�t.X�.I-•�---------------------------- Street 1 as shown on the application for Disposal Works Construction Permit Ta �� Dated__.__. DATE. /_.ram Board of Health FORM 36 508 HOBBS 6 WARREN.INC..PUBLISHERS ~—