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HomeMy WebLinkAbout0055 BAYVIEW CIRCLE - Health 55 BAYVIEW CIRLE, OSTERVILLE A=142-088 " i r ^- J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osteryille Ma. 02655 3/08/2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. o Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 renu" City/Town State Zip Code (508)428-4028 Telephone Number .License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails; ❑ Needs Further Evaluation by the Local Approving Authority - - 3/08/2007 Inspector's SigAfure Date The system inspector shall submit a copy of this inspection report to the Approving Authority @qard of Health,or DEP)within 30 days of completing this inspection. If the system is 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. 55 Bayview cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/200T " 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: ® I have notifound 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: The septic system is in proper working order at the present time. 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 pipe(s)are replaced ❑ obstruction is removed 55 Bayview cir.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 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: ❑ 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. 55 Bayview cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments �^M 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or 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 El than Y2 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. 55 Bayview cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM ,•'°� 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 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 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 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) 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. 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 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 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 55 Bayview cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �MW 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 every page. City/Town State Zip Code Date of Inspection 4 r C. Checklist 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 ❑ ® 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? El ® 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the Feld (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 55 Bayview cir.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of.15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 03 Number of bedrooms (actual): 03 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 01 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 ears usage d 2005:158,000 g ( y g (gpd)): 2006:1.69,000 Sump pump? ❑ Yes ® No Last date of occupancy: 3/08/2007 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding 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): 55 Bayview cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprise,LLc Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? measured Reason for pumping: Maintenance 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date.installed (if known)and source of information: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No 55 Bayview cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 16" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 18" Depth below grade: 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: 1 0'6"x5'1 0"x57' Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tank pumped at inspection 55 Bayview cir.-08/06 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 °M 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for osterville Ma. 02655 3/08/2007 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.): Pump tank every 2-3 years.lnlet and outlet tees are in place.Tank appears structurally sound.No evidence 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): 55 Bayview cir.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: 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 no 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.): Box is level and has one Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 1 55 Bayview cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of.15 i ' Commonwealth of Massachusetts W Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 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: 4 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.): Sandy soil.No signs of hydraulic failure.Vegetation appears normal. - 55 Bayview cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M °� 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 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 Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 55 Bayview cir.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Bayview Cir. Property Address Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 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. n 55 Bayview cir.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - .Not for Voluntary Assessments °M 55 Bayview Cir. Property Address ' Marie Resmini Owner Owner's Name information is required for Osterville Ma. 02655 3/08/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 30' feet Please indicate alll 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: as-built card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used:Gaherty& Miller model 12/16/94 Ground water elevations.Used:USGS observation well data June 1992.Used:Technical bu92-000-01 plate#2 annual ranges of ground water elevations. 55 Bayview cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 15 of 15 i I �1>;�F>�1r�•1�'2tss�t;riusetfs � ;:�` A �fay.lHntificailon Form-= ANF-001 y,.,. [3-Asbestos Abalement Description 1. Facility location:r 2f 5 .i.v r................................_..._. . .:SS C1 ............. Y°t���......__ .2c t L ..___..__. IMMUCTIous Addr`m � wme P �� � U6 a n �•, 1.Al semen of this C ti;Z(� -:....._--•--.__ _.._. ._.......... ._........_—...._.... ..._._...._........................_............_......_............_........._........ ......_.................... form mrst be car-0leled un/fwm ZIO oode rdepnoee In order to comply with FeNp artment of -_.....�.....�---^._.__— .._-....—.,—._.___..............._. Em4ertmental WW11 re%Wblf 1 907 drQQ1VAM./,*ft moo/rmm Protection moOcgiom 2. Is the facility occupied?,%ZYe_s O No rerruiemerls of 310 CUR 7.1S IW7*WkiVdqs3. Asbestos Contra pvisr noarmuon is apuaadaranyabda7wi tJeU7 �n ]Cl� SvrfC1CQ_(Yk;�n}e✓>u��e u P 8s0 propol:erd Gb wrta n -. —.__. Deparlment of labor and Industries 2yrna�i'h (Y1.8 � O p_1 �q $1-337 noliliation rwuianxis ................ ._—._..___.._._...__ .__...._...._..... ...... ........... _..__........._.._........._.._..............._....__.....__.._ of 453 ChGi 6.12 (ten GWT— lip code rdopow days prior no6r+dion s rrytiOsl oln i i f ...........................1..`T.....✓`-\ ..:r.,...._ .:......._... ............. .CcnfraY i�ye/wtlbnAerN>J-.........................................................._....._._...............__. abaterr-Y projad Vei/e' nrurw � , ow tires rarer or 3q-e 11• 4. On-SRe Project Supervisor/Foreman: 2.Submit f}Ig'vu!Form J!�"1}•c..i���� `�.__ ..._ .�:g-5---=jam�..._-_..._.___......___..._�. To: war Oil e.unoeon/ commeawealtl of Yassacbosatts 5. .Project Monitor Asbestos Program s �di�e PD3.120067 _..— .._..__._..._.................._..—.._..._.._........._.._.:..... ...._._.......__.._....._._................_.........._.......... — lutos4titA02112- wme alGroedan/ a067 _,.... 6. Asbestos Analytical Lab 3.This loan maybe used for ndilying the f"i'/.. t:U. (` .............11 .............._...._ _ U.S.Envianmenlal Protection AWxy Region lotasbestmdemolliont 7. Project startdale� vLenddateJ a'apeerficwortc hours(Mor n) (SaLSunJ i._,...._ ....._ _. ramvaGm operations sbiect to NESNAPS(40CFR ;x,y, �� 8. YYhatrypeol project is this?-(drele.one):.. ..demdlpa,... `i?: n�rs?t e"°neoo oe-(e�ramJ rQouoau�usr 9.. Describe-the asbestos abatement procedures to used (circle): gbmty aw5ssoe udconrYnrrod ddnw ao>er(LVW) tod°" 10. Is the job being conducted -K'fndoors ❑outdoors 1 .a 11. Total amount of each type of Asbesto Containing Materials(ACM)to be handled on pipes or ducts(linear it.) or other surfaces(square it.). ?16 to be removed,enclosed or encapsulated: .. linear/squarefeef -. bails;breaching.dud tanksufam ccalirps..._ rW=1',solid core pee insulation...... conupafed or taye'ed Paper pjein ublim.... insubling cur-it.................. _J spa!`an6:eprooGnp...................... bowedsprWcoalines...,.......... dalhs,worm Gbres............ . ......_J` darsile n-.0 boad............._� orw(please de=14...... 12. Describe the decontamination system(s)to be used: 13. Describe the eontainerialiotl/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): _ _-_------_ ._Lu-efs :............................................ .........._............................_......................................._.....:..... _............ _ _......._.._.._...._.._.._...._._. 14.= For,Emergency.Asbeslos Abatement Operations,the DEP and DLI officials who evaluated the emergency: `wns ntprl OrHY —. _ ._.. t .....5._:.....:...._ -.:_ .._ .. _ .�: ..... _..................._........................................__._..........._................ _...........:.........._.._..__........._._._.-_.—. . - •Qa2 d,wrroYioe WY�er/ � '. � a.. 45: Do prevailing wage rates apply as per M.G.L.e.149,§26,27,or 27A-F to this projed7 ❑Yes No �L: iI LJ Facility Description 1. Current or prior use of facility. _ZinS p ,vi 7° 2. .Is the facility owner-occupied residential with 4 units or less? Yes 0 No 3. Facility Owner. _..._.—.._......_................... Wr_ & fdep1aot'—__..__.—.._._._. 4. Facility's Owner's On-Site Manager. Address Crry/raan —._ ^27Pmde rrgvorr _ 5. General Contractor. Addnss Clry/aoan Ijo codr ConUadah Worbnr Canp.kounr pow/ Egp.Dad ' 6. What Is the size of the facility?' S2 (sq it)1 v of floors) Asbestos Transportation and Disposal 1. Transporter of asbestos-containing waste material from site to temporary storage site(h necessary)to final disposal she: { - I —--.�__.N E.s-'�—r i_L ...,..-._.. _ DSO Nine AM- . .. .. _0.. ...... ............ ....—.... l:..-.3-7— -j 7_ 2.• Transporter of asbeslos-containing waste material from removal/temporary storage site to final disposal site: USR w� +-r— 1;10 9 �iC errnoS+�-eef Note:Transfer Ub/Tan rlococb Trephine Stations must 3. Refuse transfer station and owner(if applicable): cly Wr7h the omp Sorrd Waste Dn ision►eguia- ----- tions 31O CMR �— 18.00 _ pb/lav �____......_._..__ 1b mde •(replan: 4. Final Disposal Site: , A L _i�GeiCt [ooso+Narr+ 0"is Afam - �i eaSanf Va RQc Adbna 000 COO— 11p CD* lrep5uve Certification - The undersigned hereby states,under the penalties of perjury,that he/she has read the Commonwealth of Massachusetts Regulations j for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15.and that the Information contained In i this notification Is true and correct to the best of his/her knowledge and belief. Prsiwmr— -- -- _�_ sgnarwe oytr Nob:Contractor must sign this r - N�= rn L� ).JI'j r ---...�� _ form for DU _ ___._____----._.__.._. l-33 r� nu nepem+ruq rrq�rone nofirxation purposes . Addrea h/rdwn�_...._...._ G Iil Fee exempt(City,Town,disiricl,municipal housing authority,owner-occupied residential of four units or less) yes p no "7 Sticker (from front of form): O � JAN-23-99 01 :07 AM MIDCAPESEPTIC 5087909732 P. 02 MID-CAPE SEPTIC 20 Baxter Road Hyannis, MA (508)778-M4 fax(508)790-9732 Board of Health $arnstable, MA Attn: Health Director,Tom McKean January 22, 1999 Mr McKean, In regards to our meeting on January 21, 1999 and conversations on January 22, 1999 concerning 55 Bayview Circle, Osterville, Mid Cape Septic will replace fiber poly septic tank with new 1500 gallon precast concrete septic tank during the week of February 14, 1999. The cesspool which was filled with clean sand in the front of the property wilt be reopened for health agent to examine. At that time we will again try to locate any other cesspools which may or may not be present on the property. We are glad to cooperate with you and your department. Sincerely. January 22, 1999 �a � S tqsCL�%^ q q DtaY �Um near -1 °J rah Mid Calm 't1� CZo�.gy �1 'tt i `� •p r Ly r 7 Y Ouv la eaaa c� 4i SS � Q ' z v �^-� C l v C l.e Lf � V1 Qu 11 `` oo vim— 1 a c 44%P ) II 1 1 P w, \�1+ �a h,tTT.O,/ t s . zovY' V- L-j ^n0 V TCA vLc,vr- C ie,o---*4 �, 0 -_--o �I Town of Barnstable 110 Department of Health, Safety,and Environmental Services Public Health Division 2639. 367 Main Street, Hyannis MA 02601 FD Md�t. Office: 5 - 6265 Thomas A.McKean FAX: 508-790-6304 Director of Public Health January 13,1999 TO: Owners/Managers of Cape Cod Area Food Establishments FROM: Thomas McKean,RS,CHO, Director of Public Health RE: Food Service Sanitation Training-Wed April 14,1999,Registration begins at 1:00 p.m. Training- 1:30 to 4:00 p.m. Location: Cape Cod Community College,Route 132 West Barnstable,Tilden Arts Center,Main Theatre The Barnstable Public Health Division is pleased to be sponsoring food service training workshops for all food handlers in the Town of Barnstable. Given the ever present danger of food poisoning and its impact on the customer and on your business, along with the additional responsibilities you face in serving the public, it is strongly recommended that food handlers attend food sanitation training. Also,the Board of Health policy(see back side)has been strictly enforced since January 1, 1998. It is therefore strongly recommended that you have at least two persons from each shift attend this training. The operator is responsible for ensuring that the food handler's sanitation training and certificates are updated at least once every two(2)years. The training session will be held on Wednesday April 14, 1999,at the Cape Cod Community College,Tilden Arts Center, Main Theatre. Registration begins at 1:00 p.m.. All registered students must be seated in the theatre at or before 1:30 p.m. This two and one-half hour training session will end promptly at 4:00 p.m. Ronald Herzberg,RS., of Food and Environmental Safety of America(FESA)will be presenting the workshop which is based upon ServSafe's nationally recognized employee guide,"Serving Safe Food". Each participant will receive an N.S.F. approved 0-200 degree Fahrenheit thermometer, numerous handouts as well as a certificate of attendance. The total cost will be $30.00 per person,with checks payable to F.E.S.A. Please complete the registration form below and return it along with the fee to: RJH Associates,50 Hunt Street,Watertown,MA 02172 at least seven days before the training date. If you need additional information,their telephone number is(617)926-6300. Raising awareness of food safety among your food workers not only protects you and your customers,but also assists the Public Health Division staff in working with you to enforce the State Sanitary Code. Registration Form(please print) Course Date/Location: Wednesday April 14,1999 at the Cape Cod Community College,Tilden Arts Center,Main Theatre(1:30 to 4:00 p.m.) Name(s)of Attendee: Place of Employment: Employment Address: I have enclosed$ ,payable to F.E.S.A. Mail payment to: RJH Associates,50 Hunt Street, Watertown,MA 02172 Please enroll person(s) q:wpfiles:foodsani OpIME r, DATE: O� FEE: "Vo + BARNSCABLE, MAC.g9. REC. BY� 9 ib ,0� Town of Barnsta ble ��Z� 9 SCHED. DATE: Board 'of Health t 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Ralph A.Murphy,M.D. VARIANCE REQUEST FORM LOCATION Property Address: � �'Yyt`� p a2GS� Assessor's Map and Parcel Number: Size of Lot: Wetlands Within 300 Ft. Yes Subdivision Name: No Business Name: APPLICANT ,� (� CONTACT PERSON Name: 01 C_'A0Y t t aYkp Name: Address: S `7 J y V IJAU C[r(l,p Address: Phone: 5S68 4'28— 6445- Phone: FAX: FAX: VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) -k-4 eC2 .fs G-�i Cw�,,��` - /mot off •. <� �+ov t w rP/� 6�,s�v'a g4 ems- A&-e., re; e c.'h (eJSe /.) r`y Apr. Y and s'yS 1-, -,g/4-,&air do in_5 CC�IS�Od�S d a-t tl a d V,p 0 1 i' S, Ila_f;o a..n B CL-l-F t'r t I y o le O.t S i m d7 Y,4,2f y o:d s w a-r Checklist(to be completed by office staff-person receiving variance request application) Four(4)copies of plan submitted(including septic system plans and/or restaurant floor plans) Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variances only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/leasee only],outside dining variance renewals[same owner/lessee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Ralph A.Murphy,M.D. Q:/WP/VARIREQ Oc,)kuo, ov F, �- - a-�� — c— --- --3 i -5F / J ou o� _c�wl�_ © o •o� - _` �_�' ► d� c _`- -/�-� cef S�r�v�� _ p. S_cur�_qG�G�_�-o l�i,,,� ha c,, a-r� tic G� w 0`- lti e a,i `( o la � -- --_--- . _-- r fit F # i f I t � _ i - �-- - _- _- TOWN OF BARNSTABLE LOCATION /Ile�4.,P SEWAGE # n - ' 3 VII LAGS C - �( ASSESSOR'S MAP & LOT 1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) i" �" (size) NO.OF BEDROOMS "I BUILDER OR OWNER PERMTTDATE: ? —COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 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 �....� ' TOWN OF BARNSTABLE -� LOCATION �/emse/% SEWAGE # � 5'1 VILLAGE 6 7( :,r, tl ASSESSOR'S MAP & LOTJ q` — S' INSTALLER'S NAME&PHONE NO. W4 P 4 -1 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) a. .0' (size) i le'Ze NO.OFBEDROOMS BUILDER OR OWNER PERMIT DATE: �J - 9I_COMPLIANCE DATE: Separation Distance Between,the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility"(If any wetlands exist within 300 feet of leaching.facility) Feet Furnished by �••� N .. ` � ��. �"`�- ,Q ' (�� \ � C,�i � _j ' l . � p �� �� �� . _ � , F3 a S� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Oigpool *raem Construction Permit Application for a Permit to Construct( )Repair( )Upgradey--�Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. C57� � ��T��►1� Assessor's Map/Parcel Z- 9, 4 d Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 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 1-2 3G gallons per day. Calculated daily flow �9 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank I CM Si k_t Type of S.A.S. Description of Soil Nature of Repairs 9T Alterations(Answer when plicable) --yK'S 6 5yb Lf if 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 t to place the system in operation until a Certifi- cate of Compliance has b e y t is Signed Date 7 7�� Application Approved by — Date Application Disapproved for the following reasons Permit No. Date Issued 7—-Z 7 r-,P �iNo. 9f / " F3 +-F .,. Fee 0, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for �Dfgpogar 6potem Conotruction Permit Application for a Permit to"Construct( )Repair( )Upgrade`( Abandon( ) El Complete System D Individual Components Location Address or Lot No. V r�.�0-c-\Q Owner's Name,Address and Tel.No. Assessor's Map/Parcel � � ��Q •\ in/�J 1� �� 0 �" Installer's Name,Address,and Tel.No. j5 Designer's Name,LACdldress`and Tel..'No: Type of Building: Dwelling No.of Bedrooms _Lot Size ;sq:._ft. Garbage Grinder( ) Other Ty-3e of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Z?'30 gallons per day. Calculated daily flow S t-{a gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank CR�)�5�T t Type of S.A.S. Description of Soil ;4 r y J i y Nature of Repairs Alterations(Answer when pplicable) (,I-k S 11D sue' -r(Cl `raA`� IS<JS ( 1 tL-T- L/�SfiG �r D tti-= 5 l Ui7 Date last inspected: 3 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 n t'to place the system in operation until•a Certifi- cate of Compliance has be, _ e y zt is Signed Date Application Approved by Date 7-e7-21. Application Disapproved for the following reasons . •b r Permit No. Date Issued > — Z-7�f 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 OW, 0--(G 1 -0 r—S ff(?1" at 6 04 U(-c ✓ :::I I I✓L Q.- O STF12 t t e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this perms shall no construed as a guarantee that the system will function as designed. Date ' 7 Inspector � > 0 x cl J -----u—Q------------------------------Q—J)-- No. v r /!+ .J Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=i.5poga1 *pgtem Construction Permit Permission is hereby granted to Construct( )Repair(/�)Upgrad� )Abandon System located at �' 0.� VI GcVc 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 perrad. Date: 7 " Z-7 Approved by A f NOTICE: This Form Is To Be Used For the Repair.Of Failed � . Ear Septic Systems Only. h • to''t CERTIFICATION OF SKETCH AND APPLICATION FORA g DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT . a ENGINEERED PLANS) . F hereby certify that the application for disposal winks n*ucdon permit signed by me dated 1 —��`ste . , .conoaning the, oo ; meets all of the ' PO"lowed at , . s .following aiteriv " • There are eo wetiende loaded within 100 het of the pr'oP d Wing hoiNty • There are no private wells within 130 hat of the proposed septk systan v • There b no b acme In now ower change In ose proposed . 1 • There are no rarlom requested or needed. • Ifew pltlposed Whig fkllity will be loafed within 250 feet of any wetlands.,the bottom of the proposed Whig r allity will ad be loatedless than fourteen(14)feet above the maximum adjusted Groundwater able elevation. ' i Please eomplete the h1lowwlegs A)Tbp of Ground Elevation(t000rding to the Enaineerins Division CIA reap) ' • B)Observed Oromtdweter Table Elevation(according to Neafth Division well map) ' STONED: DATE: � � t 4` LICENSED SEPTIC SYSTEM INS'I'AUM IN TR TOWN OF BARNSTABLE NUMBER_ tAlteb a aketeb 00 oNM p opened system Abe Wdo neensed Imts ie►pswon•••IhIMd plot pla. I thb plan should be sobmhted). �,a 1 «floral(bl AIt CS i � 1 a u 0 C 0 00 `Y