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HomeMy WebLinkAbout112, 114 STETSON STREET - Health 112/114 STETSON ST. HYANNIS A = 305 070 l� YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates . .(cost$30.00 for 4 year s). Abu You must do b M.G.L.- it y J business certificate ONLY REGISTERS y does not give a o YOUR NAME i g you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1" FL.(367h 11�ain Street, Hyannis, MA 02601 (Town Hall) _Z a � ' _R DATE: Fill i 3� please: wrcfc � f` APPLICANT'S YOUR NAME/S; BUSINESS N YOUR HOME J v� I V`Gc v- ` �tv-tirz- u75 y ApDRESS: 5[ _ G iV S ov AJ x*r � nza TELEPHONE # r: d Home Telephone Number ZLv— qtZ - 75L- NAME:OF EO.RPORATION: NAME.OF NEW BUSINESSZ- 16 THIS A HOMEOCCUPA IONS TYPE OF.BUSINESS T YES ..:- N0: ADDRESS OF BUSINESS MAP PARCEL'NUMBER d 7 � Asse.(:.. . ssingj When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main-Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO MISSIO ER'S OFF This indivi ual has inf ed f y pe mit luirements that pertain to this e MUST COMPLY WITH - type of business. H HOME OCCUPATION RULES AND REGULATIONS. FAILURE TO Authorized ig atare MENTS COMPLY MAY RESULT IN FINES. ' 2. BOARD OF HEALTH This individual has b informed oft p rmit r quirements that pertain to this type of business. �a orized.Signatur NUS i cu'llp Y WITH ALL COMMENTS: HAZARDOUS MATERIALS REGULATIONS` 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Hazardous Materials Inventory Sheet Checklist j Date Physical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts -( ie. gas being used to fuel machines,thinner to t'Zclean brushes all count as hazardous materials-no blanks) Storage Information - location of storage, how long is storage for? j`If none, note that. Disposal Information -where and who? If none, note that. Applicant Signature -understand what is listed and noted —Staff Initial -any-questions, know who to ask Vehicle Washing/Rinsing? give a vehicle washing policy and explain it Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. Date: i /7 / o `j TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY nnAA NAME OF BUSINESS: P 13• V et 14t LL7 40,A l: -L nn A1,0Ve A0•r A_1 BUSINESS LOCATION: I t Z INVENTORY 6 MAILINGADDRESS: ItZ 5TE75aj 5T 14y4tvovoS . AAA UZ6ol TOTALAMOUNT- TELEPHONt NUMBER: z to - q!z' �175� CONTACT PERSON: 4_4*e tires EMERGENCY CONTACT TELEPHONE NUMBER: Z10 -(<« -LI75-LI MSDS ON SITE? TYPE OF BUSINESS: f�`' �t = ^,%_ INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler* Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous 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. 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 Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer 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 �� �� 1 (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS -\ COMMONWEALTH OF MAS AC S HUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A rya CERTIFICATION c Property Address: " Y L > m . Owner .L�'s Name ;. _� t" t Owner'.s Address: A( 71 Date of'Inspection:( _ �:® �.�/��v,`IC�X'Yt;� n Name of Inspect please print) o/aeP� Q 6 Company Name- ,�' � •E/ _`' Mailing Address: -F1`•'J/'(.1�":blt� J lti ,QH• 0 Telephone Number t!' (-),e- 7 "' i. 43 ^� ° co CERTIFICATION STATEMENT : : 1 certify'that I have personally inspected the sewage disposal system at this address and that the ' formati6n—repoiied below is true,accurate and complete as of.the time of the inspection. The inspection was performed based on my:* training;and experience in the proper function and maintenance.of on site sewage disposal system. I am a•DEP approved system inspector pursuant to Section 15.340 of Title 5(3.10 CMR 15.000). The system: �, m 1/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's.Signature: Date: 6 ✓'��� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments 0 �c .i ****This report only describes conditions at the time of inspection.and under the conditions.of use at that time. This inspection does not address'how the system will perform in the future under the same or different conditions of use. Title,5 Inspection Form 6/15/2000 page 1 Page 2 of.I I . OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 41 k-okRA4 ani . Owner: 2/ `/W k YAr11rr Date of Inspection Inspection Summary: Check A,B,C,D or E/AI WAYS complete.all of Section D A:.1 vstem'Passes: I 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: - 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 subsfantial infiltration or exfiltration or to nk fatlure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. . ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)dre replaced obstruction is removed distribution box is.leveled or replaced . ND explain: The system required pumping more than:4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with,approval of the Board of Health): broken pipe(§)`are replaced obstruction is removed ND explain: `e Page 3 of 1 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTIONFORM PART A CERTIFICATION(continued) Property Address: //i ° ,✓� i�-, � L�.� Date of Inspection: � ,; 12,�71 J✓0(� y I` 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)thatthe 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: p The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of surface water supply or tributary to a surface watensupply; The system has a septic tank.and SAS and the.SAS is within a Zone l of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and.volatile organic compounds indicates.that the well is.free from pollution from that facility and ,the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other !failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of.I 1 OFFICIAL INSPECTION;FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACRSEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION(continued) Property Address: Owner. ] 9 Al VAJW Z_g Date of Inspection: , R D. System Failure y Criteria applicable to all systems: P y P You must indicate"yes"or"no"to each.of the.following for all inspections: Yes NQ e� Backup of sewage into facility or system component.due to overloaded or clogged SAS or.cesspool Discharge or ponding of.effluent to the surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the 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 %day flow Required pumping more than 4 times in.the last year NOT due to clogged or obstructed Y �� P iP e s .Number I of times pumped Any portion of the SAS;cesspool or privy is below high groundwater elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a.surface water supply. . Any portion of 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-privy is.,less than 100 feet but.greater than.50 feet.from a private water supply well with no acceptable water quality analysis:[This system passes if.the well water'analysis, performed at..a DEP certified laboratory,for coliform bacteria-and volatile organiccompounds indicates that the.well is free from pollution from that.facilityand 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 analysi&must be.attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,therefore the system fails.The.system-owner should contact the Board of Health to determine what will be necessary to correct.the failure. f E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to.large systems in addition to the criteria above) yes no _ the system is within 400 feet of a.surface drinking water supply _ the system is within 200 feet.of a tributary-to a surface drinking water supply the 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 3.10 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of l 1 OFFICIAL INSPECTION.FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTElVI:INSPECTION FORM PART B CHECKLIST Property Address: Owner ./Y/ Date of Inspection: r Check if the following have been done.You must indicate"yes"or"no"as to each of the following: . Yes No Pumping,information.was provided by the owner,occupant, or Board of Health c/ 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? /17 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 all 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: Yes no 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 CMR 15.302(3)(b)] T Page 6 of 11. OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION Property Address: Owner �j �' Date,of Inspection: L7 LOW •ONDITIONS RESIDENTIAL C0- 1�� Number of bedrooms.(design): Number of bedrooms(actual).: DESIGN flow based:on 31.0 CMR 15.203 (for )aP example: 11.0 _ d x ft of bedrooms): , Number of current residents: vae e' �1 P Does residence have a garbage grinder.(yes or no):l Is laundry on a separate sewage system (yes or no)-;�'.[if yes separate inspection required] Laundry system inspected(yes or no):j�J Seasonal use:(yes or no): 'L/_ Water meter readings, if ava' able(last?years usage(gpd)): �� ��� / Sump pump(yes or no): } Last date of occupancy: / t.< y i� COMMERCIAL/INDUSTRIAL_ Type of establishment: Design flow(based on.310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFO�RMA.TION Pumping Records Source of information: Was system pumped as part of the nspecti(Dnjyes or no): / 0 If yes, volume pumped: gallons--Now was quantity pumped determined?. Reason for.pumping: TYPE OF SYSTEM V 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). Tight tank _Attach.a copy of the DEP approval -Other(describe): pproximate age of all com onents, da installed(if known)and source of information: 7� Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 17 OFFICIAL INSPE.CTION.FORM—NOT FOR:VOLUNTARY ASSESSMENTS SITBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 17 =174) i Owne;a 1. _ Date of Inspection:/,? BUILDING SEWER(locate on site plan) V6 Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK:L./(locate on site plan) Depth below wade: Material'of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:._ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: d !/ Distance from top ofsludge to bottom of outlet tee or baffle: . . Scum thickness: Distance from top of scum top of outlet tee or baffle`. r� Distance from bottom of scum to bottom of outlet tee or baff)e: How were dimensions determine8Q. h_,P„zxy.""a-/ ,t Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels s related to outlet invert, evidence of leakage, etc.): / JI aa GREASE TRAP) (locate on site plan) L G�',,r. �' � %- �/ ' Depth below grade: Material'of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance.from bottom of scum to bottom of outlet tee or baffle: Date oflast.pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL.INSPECTION FORM-NOT FOR:YO..UNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued): Property Address: 1� —1 Owned ' _ .Rf�NSA Mit e Date of Inspection: (� + TIGHT or HOLDING TANK:AZL(tank must be pumped at time of inspection)(locate on.site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain);. ' Dimensions:' Capacity: gallons Design Flow: gallons/day Alarm present.(yes or no):. Alarm level: Alarm in working order(yes or no): Date of last pumping: Commenm(condition of alarm and float switches, etc.): DISTRIBUTION BOX:Z1 (if resent must be o ened locate on site. lanP � P )( P/� ) Depth of liquid level above outlet invert:�_1°Oat4t� &44 Comments(note if box is level.and distribution to outlets eq> 1,any evidence of solids carryover,any evidence of *akaae into or out,of box a PUMP CHAMBER: (locate on site plan). Pumps in working order(yes or no); Alarms in working order(yes or no): _ Comments(note condition of pump chamber,condition of pumps and appurtenances;etc.): Pase 9 of I 1 :OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued fl � Property Address; ) , . �. �i't✓�` e Owner Date of Inspection: rz, SOIL ABSORPTION SYSTEM (SAS): ;,./ (locate on site plan,excavation not required) If SAS'-not located explain why: k .. 1. .. ... Type le.china pits,number:_ eaching chambers,number: leaching galleries, number: leachins trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Zype/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): e;00y� '� g _y /�/�f a lul CESSPOOLS:/'"tt(,J (cesspool must be pumped as part of inspection))((lloocate on site plan) Number and configuration: Depth top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY I (locate on site plan) Materials of.construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART,C S.YSTEIVI`: FORMATION(continued) Property Address: Owner q .f� Date of Inspection: n11A 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. 70 i ;I� ' , �c " n� - � d 16 Page 11 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: ':Mf p Date of Inspection: SITE EXAM Slope Surface'water Check cellar Shallow wells Estimated depth to ground water Meet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: /Checked with.local excavators, installers-(attach documentation) r�Accessed USGS database-explain: You must describe how you established the high ground water elevation: - 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION. J .may ._ ' Site Location: % l! /(� � Lot No. Owner:: A A7/, Address: i Contractor:... tr�/4-0 . t Ire � Address Notes: STEP 1 Measure depth to water table i tonearest 1/10 ft. .................................................:............................. .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site.and determine / 4-/ OA ,Appropriate:index well ......................................... Water level range zone .....::............................... STEP 3 Using monthly report':.".Current Water:Resources=Con'ditions deterrriine current depthao water level for index well ! ' month/year STEP 4 Using Table of=Water level-Adjustments :for index well (STEP::2A),.:current-depth 20 water-level:for::index-well-(STEP 3), and water level zone (STEP 213) determine water-level:adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water A level at site (STEP 1) ................................... L t Figure 13.-Reproducible computation form. 15 -- �w _ �. f t ��\ .` .� I '- �, �� � � . - � � - 9 �: . _ �� _ _ j _.__._ Y - � � � �' �� �:� . '_ � � �- �1 :. . ;; ,. �� �� -� � . : . � � � �1 � �� �=� . . j . � � ��� . �� ._ � �� �-� _ �c�, � =� � 4 TQYt . Q)F BARNSTABLE /v ✓ L3 ATION / ;L / /4�7 S I e 156 SEWAGE # VEV-AGE Ream / ASSESSOR'S MAP &.LOTS 306 070 INSTALLER'S NAME&PHONE NO. 66 ��-�e �'- `���`�`' L l SEPTIC TANK CAPACITY 16`,s,0 LEACHING FACILITY: (type) ,��' L' (size) / 7 5 NO. OF BEDROOMS BUILDER OR OWNER Lf/mot X Af PERMIT DATE:<— 6 / COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater'Table and 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 k Furnished by h � F � 1 x �� � ��_� � �--� i' 6 -�--� �� . I t� ; � �_ •-s� /� N o Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zippfication for Miopogar *p6tem Congtruction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 112 114 Stetson St. , Hyannis Wernick Properties Assessor's Map/Parcel 44 School St. , Boston, MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures s' Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) T i j:1Q_5 1£aGh Syrt eM :EA 4 bedrooms, consisting of a D-box a-nd 3 prar•ast 1eanh chambprs with stone all around. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ued by!pis B�Td of Health. / Signed .L(��.�, ✓L Date •�`'�� Application Approved by Date= � 1 Application Disapproved for the following reasons Permit No. ,_7 ��5Z - Date Issued �'` � 4ErJ� _Zl I T M IS TOWN OF BARNSTABLE. Nil LOCATION i l Z .r SEWAGE # 61 VILLAGE ASSESSOR'S MAP & LO?. 07 0 4 INSTALLERS NAME&PHONE NO. A 6 6 S SEPTIC TANK CAPACITY, LEACHING FACILITY: (type) J 4- C (size NO. OF BEDROOMS, I. bMDERbk:OWNER PERMITDATE: COMPLIANCE DATE: 0 SepatAtibn Distance Between.the: Maximum Adju§ted,Groundwater Table-and Bottom of Leaching Facility Feet PrivatelWater Supply Yell and-Leaching Facility (Ifany wells exist on site or within 200 feet of leaching facility) - Feet Edge of Wetland and Leaching Facility,(If any wetlands exist Feet within 300 feeCofleaching facility). Furnished b' y__ ........... P0 s No. /c.7�rd Fee 5® r•, THE COMMONWEALTH OF MASSACHUSETTS E tered in computer: PUBLIC HEALTH DIVISION TOWN OF BARNSTABLES MASSACHUSETTS 0[ppYication for Migooal *p-5tem Con!gtruction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 1 1 2 1. 1.1 4 Stetson St. , Hyannis Wernick Properties Assessol'sMap/Parcel G / 44 School St. , Boston, MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ✓ ' w Wm. E. Robinson Septic Service P O Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other ' Type of Building No.of Persons Showers( ) Cafeteria( ) ` Other Fixtures Design Flow gallons per,day. Calculated dailyflow gallons. Plan Date Number of sheets 4- Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system for 4 bedrooms, consisting of a D-box and e`a leach chambers with stone all ,around. v.Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i ued b is aril of ealth. Signed l` � Date .S a l Application Approved by Date Application Disapproved for the following reasons 4 Permit No. �� ��� ` Date Issued ------------ ` ----------------P- ----- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS »ernick, ` Certificate of (Compliance THIS IS TO ERT Y,MoDinson the On-site S wag pisp al S s em Constructed( )Repaired ( X)Upgraded( VCJIII. Se is er�iitce Abandone�( )by at112 114 Ste' soon'S . , Hyannis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permi e,47/—Z-;; ' dated Installer Wm. E. Robinson Sr. Designer The issuance of this pe hq1I not be construed as a guarantee that the syste ill fu 1�610 s design d. Date 6 Inspector ` _ No.° 6 .�� ------------------------Fee $50 THE COMMONWEALTH OF MASSACHUSETTS ��---- PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSE S Wernick iopoo em C-ohgtruction Permit F Permission is hereby ranted o Construct( )Repair(X )Upgrade( )Abandon( ) System located at 12 1 1 4 Stetson St. , Hyannis and as.described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title+5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thi ermit. Date: d�� Approved �— 7's uat�s s �NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. Mr1r iCAMON OF SKETCH AND AP111CAMON FOR A DISPOSAL WORKS_corg tUcnoN PERMff{WiTHpUT DES[GNED PLAN$j William E_ dobinson.S>q y certify dw the application f.,r disposal works. construction permit signed by me dated "11 (:)-/ -,concerning the prop"located at 1 1 2 L1 1 4 ,qtet D St_ , Hyann; s meets all of the fouowing criteria: • The failed system is to a residkntiat dwelling only. There are no commercial or business uses associated with& • The soil is daesi5ed CLASS I and the percolation rare is less than or equal to 5 minutes per inch Thac arc no wetlands within 100 feet of the proposed srptsc ati3tem - There arc no well$within 150 tat of the proppsld Septic s}�e There is no i in flow and/or in use • There are no requesmd or needed. - The bottom the proposed leachmg b=W will W-be low less than five feet above the maximum ed poondwater table devatiom (.Adjust the groundwater table using the Frimptor method w abiel • If the S.'-S_will be located with 250 foe[of any vegetated wetlands.the bottom of the proposed leaching bdiky wiH am be dared less than faurtee,t(14)fee,above the maximum adjusted g umdwvata table elevation, Please aomplae the fidewiW A) Top of Ground Surface Etevatian(using Gts in6otttotation) B I G.W.Elevation +tk MAX. WO G.W_Adfintment DIFFERENCE BETWEEN:A and B t SIGNED ,. ./`� ✓ `- A � DATE: l� (Sketch PMPosed Plan of sysuao on backi. ,,:ncaten r w-ccn f r' i COMMONWEALTH OF MMSACHUSETTS • EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 112 / 114 Stetson St. yannis Owner's Name: Wernick Properties Owner's Address: 44 School St. Suite 710 Boston MA 02108 Date of Inspection: e G — 0. 1 Name of Inspector:(please print) Wj 11 jam E_ Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5 0 8) 7 7 5-8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported' below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and.maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Sec n 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:_4r,,6e ! ,�� 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 approvm* g authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: 1 1 2/ 1 1 4 Stetson St. Hyannis Owner: We nick Date of Inspection: — 4- Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste Passes: I 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 Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or re aired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please exp in. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exist ng tank is replaced with a complying septic tank as approved by the Board of Health. •A n ietal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic ating that the tank is less than 20 years old is available. ND xplain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or ob cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appr val of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a plain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed N explain: l Page 3 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address112 / 114 Stetson St. Hyannis Owner: Wernick Date of Inspection: •- —O 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 fa ling 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 sy em is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The se system has a tic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a Y P 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 acteria and volatile organic compounds indicates that the well is free from pollution from that facility and he 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. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued)' Property Address: 112 / 114 stetson St.- yann1s Owner: Wernick Date of Inspection: — ® -? D. System Failure Criteria applicable to all systems:. Y' u must indicate"yes"or"no"to each of the following for all inspections: Ye No _ = Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS of cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z 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 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. 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. L rge Systems: To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You st indicate either"yes"or"no"to each of the following: (The flowing criteria apply to large systems in addition to the criteria above) yes o 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 . If you ave answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" n Section D above the large system has failed.The owner or operator of any large system considered a signi scant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15. The system owner should contact the appropriate regional office of the Department. 4 `Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 1 2 / 1 1 4 Stetson St. Hyannis Owner: Wernick Date of Inspection: l Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health IX-- Were any of the system components pumped out in the previous two weeks? Ha 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 all 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: Yes no 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 CMR 15302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 112 / 114 Stetson St. Hyannis Owner: Wern i ck Date of Inspection: y- 6 FLOW CONDITIONS RESIDENTIAL L�, Number of bedrooms(design):�L Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):A, 6 Is laundry on a separate sewage system(yes or no): sb [if yes separate inspection required] Laundry system inspected(yes or no): 11 i7 Seasonal use:(yes or no): Ae U Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 0 135, 000 gal. Sump pump(yes or no): 4le U 1999 132,000 gal. Last date of occupancy: CO MERCIAL/INDUSTRIAL Type establishment: Design ow(based on 310 CMR 15.203): gpd Basis o design flow(seats/persons/sgft,etc.): Grease ap present(yes or no): Industri 1 waste holding tank present(yes or no): Non-s itary waste discharged to the Title 5 system(yes or no): Water eter readings,if available: Last d e of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: b A !�� `� — G G— a ? Was system pumped as part of the inspection(yes or no):_,d., c,2 If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: i,- A ),I YK TYPE OF SYSTE M LSeptic 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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):*D 6 Page 7 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 / 114 Stetson St. yannis Owner: k Date of Inspection: — ® l BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:—"(locate on site plan) r ► Depth below grade: - Material of construction: ✓concrete—metal—fiberglass—polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes.or no):—(attach a copy of certificate) l Dimensions: Sludge depth: Y Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: y Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or b e: _ How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): REASE TRAP:—(locate on site plan) D th below grade:— M terial of construction: concrete metal fiberglass_polyethylene—other (e I lain): — — — D' ensions: Sc m thickness: Di tance from top of scum to top of outlet tee or baffle: Di tance from bottom of scum to bottom of outlet tee or baffle: D to of last pumping: mments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels related to outlet invert,evidence of leakage,etc.): 7 Page 8 of l] ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 2 / 1 1 4 Stetson St. Hyannis Owner: Wernick Date of Inspection:/—Z ., TIG or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth low grade: Materia of construction: concrete metal fiberglass_polyethylene other(explain): Dimensi ns: Capaci : gallons Design low: gallons/day Alarm esent(yes or no): Alarm 1 vel: Alarm in working order(yes or no): Date o last pumping: Comm nts(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): i 8 i Page 9 of I l OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 / 114 Stetson St. Hyannis Owner: Wernic Date of Inspection: Cl7 SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required) If SAS not located explain why: Type eaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic /Afailure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet inve Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PR (locate on site plan) Mat rials of construction: Dim nsions. Dept of solids: Conu ients(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 / 114 Stetson St. Hyannis Owner: Wernick Date of Inspection: 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. 4d :1 J 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 / 114 Stetson St. Hyannis Owner: Wernick Date of Inspection: SUE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 19 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how yoS stablished the high ground water elevation: v 11 'TOW'! .-`)R BARNSTABLE LOCA,TION 7Z 166 !` SEWAGE # VILLAGE G ASSESSOR'S MAP & LOT 70 INSTALLER'S NAME & PHONE NO. Z 2 SEPTIC TANK.CAPACITY LEACHING FACILITY:(type) ,c. ) i �f ez 9..t as i (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER � BUILDER OR OWNER . . V1 a 4 DATE PERMIT ISSUED: - d DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �;; . rt t, .i y tt s. �`J ,� \ .. .� S v_ I� � � �` i 1\1 � - � � n 1.� � �� � � �'���i �. L.__ o No... ^.r ��...7' .02 Fizs3II::00............._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Applira#ilan,-for Elhipas al Marks Tnnitruriinn Frrutit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 112 Stetson St ................_........._.......... - --------------------•-•••-----------••----..... ........... ---•----------------------...._.-------•------••-_----- Location-Address or Lot No. aS...WaxxljXk................................... ............................... Robinson Septic Service P 0 Box 1089 Centerville Installer Address Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms.............................. ...._Ex Expansion Attic�-+ g— --------- p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures -----------••------------------------------•---------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit---:................ Depth to ground water........................ x Description of Soil.............. V .........---•-••----••--...--••---------------•----..........---•--•-•--•----------•------------...-----...----•••---------••--------••----•---• ----------------•--•--------.....------•--------------------------------.........................•------•---------------------....----------•----------•--------------------------•--•-•------•------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..... rscast...stanepaciced..leach.-s rstea........-•---•--•-----------------------------------•--------------------. ........................................... 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 undersi ned further agrees not to place the system in operation until a Certificate of Compliance has been issued the oard of hea . Signed -------- L L ..... ;-- - ------------------------ --- ---------- (1..--_�.....------------------- Application ' Dare Aroved B :c� --------------------------------------------------------- -----�..^.. �...... PP y ------------ ------------ ------- ete•Y,�-•-�... to Application Disapproved for the following reasons- ------------ ----------------------- - --------------------------- --------- - ------- ---------------- ----------- -------------------------------------------------- --------------------------------- -- -------------- ------------------- -------------------------------- ----------------------- -- ....................................--- e Permit No. ---.21,PA-'-----ly -.7............................ Issued ......................... Da' --------.......---.......-- a' Date No...lrzZ. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �-- TOWN OF BARNSTABLE Applira#ion for Dhipos al Works Tnnstrnrtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 112 Stetson St __..._ .............. ................................................. ......................................................._.......................................... Location-Address or Lot No. • - .I�? +l.�frk----------------------------------------•----------......•........ ..........------------............................................-.-........-.......•----------- Owner Address W W.E. Robinson Septic Service _ _ _ P O Box 1089 Centerville a ------- Installer Address Type of Building 3 Size Lot............................Sq. feet I.I Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building No. of persons ................... Showers YP g ---------------•------------ P ( ) — Cafeteria ( ) dOther fixtures -----------------------------------•---------------------------------------------------------------------•--..----- ............... 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 ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 t •----------------------------------•----....----•----------•--....-----......---•---•----•-----••-•--•----•-••--•-•---.-.------.-.---------------•----------- ODescription of Soil------sarict............•..................................................----------------------------------------------•--------•-----------------------....._.. x U w .........----------------------------------......................................................-...........................................-.......................................................... U Nature of'Repairs or Alterations—Answer when applicable.............................................................................0.................. r�rrxa St• St(�nP CIC ...�Aarh-.cvcLam......................................................................0............................................... 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 been issued by-the board of health? Signed ' r..✓..` .i' < -_-------- l_/t..�^: r ` .- �f•'�-- Date Application Approved BY 1; t cam . �----- -------------------------------- ". 0--- 11) U � Application Disapproved for the following reasons- ---------------------------------------------------------------------- -------------------- -------------------------------------- ................................... Permit No. ......7�.. --.7q-7 r�.e ------------------------- Issued ------. ------------------------------.---..... .. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C11ezti#irate of Q-1-uxnplian.ce t THIS S TO CERQ1Q.That the,Individual Sewage Disposal System constructed ( ) or Repaired ( X ) W t; Robinson p is service by ----------------------------------------- Insmller ,. at1 1 2 Stetson-.St. Hyannis -------------------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit NO. ........j�.04.. Yo.7......-. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------------ ------. . Inspector --------------� � .......................................... ;r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.....�,� ..... - FEE.10.,.0()............ Mnpnnatl Voirthill Tun#rndioln rrndt Permission is hereby granted .................................................................... to Construct ( ) or Repair (X ) an Individual Sewage Disposal System atNo...1?-2--stctgf,�. _xx..n ----------_--------------•----------••--------------------------•----------- Street g as shown on the application for Disposal Works Construction Permit No..YSL,� . Dated.......................................... -----------------•-------------------- ----------------...-- = - .................................. Board of Health •. DATE................. �=�--•-�7- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS • .t 4 .......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTFU APPROVED TOWN O F BA R N STA B L E '' able Conservation DeDertrh�t ,c ppliration for Uhip sal Vork.6 Tomitrud Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: /���Scj� c rS7" ./ram.�..... ....... --------------- rv�s------------ ----------...--------------------- -- ----------- -------- ------------ ----- Loca Address r Lot No. Owner Address Installer Address Type of Building It Size Lot.A-3 06 .f-:Sq. feet aDwelling—No. of Bedrooms.............. ........._............_Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------•------------.......-----------------------------------------------•---------•--------.......-•-•-••-----•--••- W Design Flow............................................gallons per person per day. Total daily flow------------- ...................gallons. WSeptic Tank—Liquid capacity/-0.6-- _.gallons Length_,l&.57.. Width_.__,_-'.� ...._ Diameter................ Depth................ xDisposal Trench—No........... ...... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. . Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0�4 Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................ a .-- O Description of Soil > Ole x ....................................../� •-•-•- ......... W U Nature of Repairs or Alterations—Answer when applicable.--____.�� ._.___._. __ —>� C< r�S_.._ __ -----i-- 7ZJhl�............................................................................................................................................................................... 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 Complianc s •een •ss d he board f health. Signed ------ -- -------- - ------ -- -- Date ApplicationApproved By ..........C ..... ........................................................................... -- ..r�- Date Application Disapproved for the following reasons- ----- ------------- - -- -------------------------------- ------------------- -........................................ -------------------...............................----------- ....................................- Date PermitNo. y --------------------- Issued ............................................ . - Date • No.s............._....... � Fps.._........._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF - HEALTH TOWN OF BARNSTABLI �� Appliration for Dispasal' Works Ton/trnrtutnn efmit ,f Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: f57 --------------- .._...,���-FLU-=S------------ --------------_..._..._.....__....---- --- - ------------- .-.. Location-Address or Lot No. - _ isj c� -`-S7 . .................... •----•-----------•---•-••- ------ --------- Owner Address Installer Address Type of Building Size Lot__ l_�__.®__---Sq. feet U Dwelling—No. of Bedrooms...............!�.......................Expansion Attic ( ) Garbage Grinder ( ) `.1 Other—T e of Building No. of ersons--------•-•----------------- Showers a yP g P ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------------.--••---------------•-•------ 11 W Design Flow----------------- _--•-------•-.-_gallons per person per day. Total daily flow............l'--l1Kj--------------------gallons. WSeptic Tank—Liquid capacity/�..gallons Length__/A,5— _ Width.....5--- 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. 1................minutes per inch Depth of Test Pit-_______-_----__.--- Depth to ground water--___-_--------------_:_ f=, Test Pit No. 2----------------minutes per inch Depth of.Test Pit.................... Depth to ground water------------------------ xJ ----------------------------------------------- 0 Description of Soil.........( �_- Z S� # -- c -----------�� - x -C14�Y-----=----`-5C - C>/L `' —==--`---11---.__.._.. V ------•----------------------------------------------------------•-•----------------•------•--------••---------------------•----------------------------•-------------_-----------------•--------------- W U Nature of Re airs or Alterations—Answer when applicable_..._... -------------------� �L-.- --- ____. S�CJjv 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-as Peen 'ssu d b)-the board of health. Signed . .... ;� ' '� - -`-------------------- --- t\�•�' _ Date Application Approved By --------- (,�j.--r��/\ -Gsn�-� ----------------------------------------------------------- --------------- -- '- .. V V Date Application Disapproved for the following reasons- ...............................................-------------------- ---------------------------------- -------------------------- -------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- ---------------- -------------------- ____Permit No. � `-----V©_.F-------------------- Issued --------------------------------------------------- Date----- .....______ ___ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�ertifira a of Tomplinurr F THIS IS TO CERTIFY, Th t the Individual Sewage Dispo al S stem constructed ( ) or Repaired ( ) by------------------------------------------------------- fit Gp ------G s? G�� �a N -`' - Installer ................/___ ----------------------------------------. 75- at ---------------------------------------------------- /'G�S' /�,-- ��L� -1 � �r'tJNi_5 has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..-.-_..�� ..-.__ !. ._ ------- dated ________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATEO /- { ---------------------------------------------------- Inspector -------- ---------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH u TOWN OF BARNSTABLE No... __.._/._d FEE---- 6.. �t��n�a� �ark� ��an�rnr#uan rruti� Permission is hereby granted.................... ----------G��� � r -� to Construct ( ) or Repair (x)/an Individual Sewa e-Disposal, System at No................................................ G.3 _ /<o- -------� /490, l - - ------------ ...•. Street as shown on the application for Disposal Works Construction Permit :. d _ Dated-------------............................. ................................. '�----------------------•---------__-----------------••_ .................................... Board of Health DATE............... _- �' FORM 3830E HOBBS d WARREN.INC..PUBLISHERS