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HomeMy WebLinkAbout0195 BUMPS RIVER ROAD - Health (2) 195 BUMPS RIVER&D OSTERVILLE Sao- oya-oo� - -- . - � u TOWN OF BARNSTTAQLE LOCATION S- c�vv,.A ;t,�J`' ��LL SEWAGE# VILLAGE®Sr>--k.+'%`tom ASSESSOR'S MAP&PARCEL Dp ST S NAME&PHONE NO:;��---R�R SEPTIC TANK CAPACITY TM 6P�5 LEACHING FACILITY:(type) L- �c� � (size) t®�� ( �✓� NO.OF BEDROOMS OWNER PERMIT DATE: 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 h _ 1 � c 6 0 `a Commonwealth of Massachusetts Title 5 Official Inspection Form 'COPY o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farm/ Harry F. Johnson Owner Owner's Name information is required for Osterville MA 02655 December 12, 2012 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. Please see completeness checklist at the end of the form. Important: A. General Information When filling out ((( forms on the computer,use 1. Inspector: I �VVV only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter Excavating Company Name P.O. Box 89 Company Address Forestdate MA 02644 " Cityrrown State Zip Code 508-888-6055 SI 12843 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 December 14, 2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins—11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of'1 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farm/Harry F. Johnson Owner Owner's Name information is required for Osterville MA 02655 December 12, 2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) 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 js 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.. ❑ Y ❑ N 0 ND (Explain below): t5ins•11/10 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farm/Harry F. Johnson Owner Owner's Name information is required for Osterville _MA 02655 December 12, 2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 / ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed �/ ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or,eeplaced ❑ Y ❑ N ❑ ND (Explain below): % I ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ;T 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�o 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 t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,,. 195 Bump's River Road Property Address Johnson Tree Farm/ Harry F. Johnson Owner Owner's Name information is required for Ostefville MA 02655 December 12, 2012 every page. City(Town State Zip Code Date of Inspection B. Certification (cont.) 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. ❑ 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 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 must be attached to this form. 3. Other: ' II 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 El clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ® or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•11/10 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farm / Harry F. Johnson Owner Owner's Name information is Osterville MA 02655 December 12, 2012 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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 coliforrn 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 f et of a surface drinking water supply ❑ ❑ the system is within 0 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) a mapped Zone II of a public water supply well If you have answered "yes"to an question in Section E the system is considered a significant threat, or answered "yes" in Section D ove the large system has failed. The owner or operator of any large system considered a significE7(threat under Section E or failed under Section D shall upgrade the system in accordance with 3 0 CMR 15.304. The system owner should contact the appropriate regional office of the Depa ment. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farm/Harry F. Johnson Owner Owner's Name informat required fonds Osterville MA 02655 December 12, 2012 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were 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 field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.2031or example: 110 gpd x#of bedrooms): t5ins-11110 TRie 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 195 Bump's River Road Property Address' Johnson Tree Farm/Harry F. Johnson Owner Owner's Name information is required for Osterville MA 02655 December 12 2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Office Design flow(based on 310 CMR 15.203): 200 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 400 Sq ft 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: 2011= 128 GPD 2012= 128 GPD t5ins•11110 TNe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farm/Harry F. Johnson Owner Owner's Name information is MA 02655 December 12, 2012 required for Osterville every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: Owners records: Pumped 4 yrs ago Was system pumped as part of the inspection) ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system El Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by,system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farm/ Harry F. Johnson Owner Owner's Name information is required for Osterville MA_ 02655 December 12, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed approx. 1973. Owners records. No plans on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2,2„ Depth below grade: feet Material of construction: ❑ cast iron. ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1't P 9 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5'X 5'X 4.5' 1000 gallons Sludge depth: 1 t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road, Property Address Johnson Tree Farm/Harry F. Johnson Owner Owner's Name informationrequired for eq Osterville MA 02655 December 12, 2012 every page. City/-Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet concrete baffles in place. Liquid level at outlet invert. Covers are within 6"of grade. Pumping not needed at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ iberglass ❑ polyethylene ❑ other(explain): Dirnensions Scum thickness % Distance from top of scum to p of outlet tee or baffle Distance from bottom of s m to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11I10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farm/Harry F. Johnson Owner Owners Name information is OSterville required for MA 02655 December 12, 2012 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fi rglass ❑ polyethylene ❑ other(explain): 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•'' 195 Bump's River Road Property Address Johnson Tree Farm/Harry F. Johnson Owner Owner's Name information is required for Ostefyille MA 02655 December 12, 2012 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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 ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump c/er, dition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farris/Han F. Johnson Owner Owner's Name information is required for Osterville MA 02655 December 12, 2012 every page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: stone. tonn e . 6'w! st . ❑ 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 failure, level of ponding, damp soil, condition of vegetation, etc.): - Liquid in leach pit 5' below invert at time of inspection. High water staining 4'6" below invert. No sign of past hydraulic failure. Leach pit appears to be H-20. Lid of pit is 8"thick. Cover is within 6" of finished grade. 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 constructio Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 195 Bump's River Road Property Address Johnson Tree Farm/ Harry F. Johnson Owner Owner's Name information is required for Osterville MA 02655 December 12, 2012 every page. Cityfrown State Zip Code pate of Inspection D. System Information (cont.) 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 s/ignsoflic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farrn/Harry F Johnson Owner Owner's Name infomlat;on is Osterville MA 02655 December 12, 2012 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �.___,.�- ,.Uj,lr�►�1 FPS �I V�� �� '� I n _ 3a= 3 [sins•11110 Title 5 Official Inspection Form:Subsw1ace Sewage Disposal Sin Page 15 of 15 Commonweatth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farm/ Harry F. Johnson Owner Owner's Name information is Osterville MA 02655 December 12, 2012 required for 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 high ground water: >5 feet. Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators,installers- (attach documentation) ® Accessed USGS database- explain: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Property elv.= 40. Base of leach pit 8' below grade (elv= 32). Accessed local ground water contours and topo mapping. No high grond water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 116 of 16 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Bump's River Road Property Address Johnson Tree Farm/ Harry F. Johnson _ Owner Owner's Name information is Ostetville MA 02655, December 12, 2012 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 17 of 17 YOU WISH TO OPEN A BUSINESS? .., For Your Information:; Business certificates (cost$30.00 for years). A business certificate ONLY REGISTERS YOU You must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1" FL. 367 R NAME in town (which Main Street, Hyannis, MA 02601 (Town Hall) G , DATE: o `I - 20 1 0 APPLICANTS Fill in please: ' YOUR NAME/S: ;-A G( Px 7 ?at a� 7r, BUS NESS YOUR'HUME ADDRESS: - .3(,•3,7(' a ).a.'F". � ��TF -�,+1J'(/ ZO Z - d'aft .k r t Nr�9 az 3 TELEPHONE # Home Telephone Number NAME OF CORPORATION: d !a,! NAME OF.Pf/CJ:BUSINESS !c h.Jd� �¢.,C to. 1S THIS A HOME OCCUPATION —YES' NO ADDRESS OF:BUSINESS TYPE OF BUSINESS Y�G rn1 MAP NUMBER t Z:GO.;C�Zoo. DZ6S'S` . (Assessing): When starting a new business there`are several things'you must do in order to be in compliance with the rules and regulations of the Town of Barnste'ble. This form is intended toassist you in obtaining the information yo Rd. & Main Street) tomak u may need. You MUST. GO TO 200 Main St. — (corner of Yarmbuth Ae sure you have the appropriate permits and licenses required to legally: 'operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has.been informed of any permit requirements that'pertain to this type of business. Authorized Signature COMMENTS: 2.,BOARD OF HEALTH This individual h een infor e o t e p r it requir merits that pertain to this type of business. nl Authorized S' nature*.* COMMENTS: . 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This in has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** T COMMENTS: 1 Date: 0 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: d�InJM ✓te )5*vwn Tr BUSINESS LOCATION: s `�'� OJ/`f'il� *' &a INVENTORY MAILING ADDRESS: w &X l��6 df rv�'� M�1- OLG J S� TOTAL AMOUNT: TELEPHONE NUMBER: Sot ` U ZZ3� CONTACT PERSON: it-f— Njwe-t( EMERGENCY CONTACT TELEPHONE NUMBER: 50 3Z6 GGto MSDS ON SITE? TYPE OF BUSINESS: T frc IGa✓� 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 Qoy be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS No. -----ann� -0 Fee---- --------------- BOARD OF HEALTH TOWN OF BARNSTABLE Application,forlVell.Conotruction3Perrnit Application is hereby made for permit to Construct (t/), Alter ( ), or Repair ( )an individual Well at: Sy ,� .c 1 DSis%,, l — J� Location — Address Assessors Map and Parcel 4A# Owner / Address -------- ------- - -- Installer Driller Address Type of Building Dwelling_ - Other - Ty e of Building--------------- No. of Persons------------------------ - T 'oo Well ----------- Ca acit Pu ose of Well-----��f- 'Q ---- - -- — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed ---- - -A lication Approved By — - --;4 - 101 PP &_ 7 dat Application Disapproved for the following reasons.---=----------------—- -- - ---------- date ��. Permit No. � ---- Issued---- --��----- ------------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (t-f Altered ( ), or Repaired ( ) -- (/ — —Installer — at--�_—dflz �SP —��------- —---------- --- - -- -- has been installed in accordance with the provisions of the Town of Barnstable Board of Health�te Well Protection Regulation as described in the application for Well Construction Permit No. - . ted--- -------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- -------— - —— Inspector---------------------------------—--------- No. ---- 00 Fee--- --- BOARD OF HEALTH - TOWN OF BARNSTABLE 1 Zipp cation-*rVell Con0ruction.permit Application is hereby made for a permit to Construct (✓)_Alter ( ), or Repair ( )an individual Well at: Location -"Address Assessors Map and Parcel Owner _ -- Address l ell Installer Driller ( Address Type of Building ,�. Dwelling - /f L�fe_ A -- - ---------------- Other - Type of Building-------------------- No. of Persons--__ Ca r_�_ acit -- Ty$ of Well - - _- — P Y---- -- -------- uPu ose of Well-----/�f%.� Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed `t- � ----- — 1� �/�%��Ulo --- date Application Approved By / - - 7 date, E Application Disapproved for the following reasons: -=------ - ----------- - — date Permit No. Issued--- �__�_ ate_ � � d ------------------- i BOARD OF HEALTH TOWN OF BARNSTABLE Certifitate Of COMPhance THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), or Repaired ( ) -------------------------------------------------------------- Installer at— /7`i— U �_S%a z-/ —__—----- -------------- --------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Prwalte Well Protection Regulation as described in the application for Well Construction Permit No. -------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------- —-- Inspector---- --- - ----------- BOARD OF HEALTH TOWN OF BARNSTABLE Veil Con$tructionpermit No.l-_ /1 2 6J067 r Fee_ T Permission is hereby granted N^4<,,�✓,��� ''�'�� ��f��" - --- --- --— to Construct ( V), Alter ( ), or Repair ( ) an Individual Well at: No. --- street as shown oxi the application for Well Construction Permit f �r/ j' ------------------------------- No.---- 1/� � _(�4�iv � l ------- Dated=^ `�, .�---____— ='------------------------------------- Board of Health DATE C , r ( ` '' � 0__5 ®_ 2 Fee---� No. ------- — BOARD OF HEALTH � TOWN OF BARNSTABLE App[icationjorlVe1[ Con5tructionPermit Application is hereb a for a permit to C st uct ), Alter ( ), or Repair ( )an individual Well at: ®ui Location — Address Assessors Map and Parcel 2i\M �4 --(D I 'Owner Address CG ! _S — _�_1c L-( lc 'GC!_ (> go �� Installer — Driller Address Type of Building Dwelling---------------------------—-------------------- Other - Type of Building j5zbop- No. of Persons--- ----- Type2-0 of Well-----=--��------ -- Capacity—---------------------- Purpose of Well---- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operatio unti a ate of Compliance has been issued by the Board of Health. S' ——-- ---- ^—q - ----- date Application Approved — --—- -—-— —`3 -- date Application Disapproved for the following reasons:—------------ - —--—— - -- ---- -- ---------- — -- ------------ date Permit No. Issued-- -- — ------ -----— date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of (compliance THIS I TO CERTIFY, That the Individual Well Constructed; Altered ( ), or Repaired ( ) by------- lq,!EA -- ---\-- - ---- -- --- - - -- - — --- ----- In taller` C has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No� 52Dated -� ---- - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------- ----- —-- Inspector-- --- - -- -- ------—---- Jr --��---0#az Fee--- ----- ----- BOARD OF HEALTH V TOWN OF. BARNSTABL.E' Zpplication-*rVell Con0ructionVerurit Application is hereby de for a•permit to Co struct ), Alter ( ), or Repair ( )an individual Well at:,' ` � S t 0 42 - o d t Location.—;Address Assessors Map and Parcel T0 �AJSO,&j T46E C t S' c3t�N1Q�-21.R `?A o vlr='�_c, 1 -- r—�— Owner — ------- — Address .� c..� �q._Q .V lLY'u-_ 1 �-(Itl��.,- UGC"i v/ —�x -�3q t A-�=` Installer — Driller Address Type of Building Dwelling ----- -- ——---- Other - Type of Building No. of Persons------------- .: Ei Type of Well LAW•!o�t'46 - — Capacity �'� �� K. Purpose of Well (���� -------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operatioryun'til a� •icate .of Compliance has been issued by the Board of Health. Signed.,.�. —-------- -- - date (, Application Approvedy _ ._. ---+------— -- :--�� ]- - date Application Disapproved for the following reasons: date — ��y Permit No.-� � "' - — Issued-- - "�- - — -- - date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed,4%%)., Altered ( ), or Repaired ( ) a = - -- - --- ------------------------— - -- - --- --- ---= Installers (� , at Q ( �2!13 has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No - Dated t7J aul-�5- r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- -- --- —= Inspector-- - ----- -- ------------ BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Construct ion i3ermit No. \��, `—' Fee- --- Permission is hereby granted to Construct (Y)"4ter ( ), or Re air ( ) an Individual Well at No.. -- —1 - -_- _a �-- -— —'- - - - - - Street as shown on the application for a Well Construction Permit , No.- -- _ �? =------ Dated--.--- ---- ----------------------------------- --- ---------------------- -------- p Board of Health DATE t -- Sti0 Co 1� ,0 bA&L� '!! lZS `�3��tPS2t AA A(o PAP© �s t. K . lit S' /L/LCGr fit rR, �Yy .i, . TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: 77• /Oku'0A Ze �,-s+, Mail To: Board of Health MAILING ADDRESS: 1 er- 0 Town of Barnstable TELEPHONE NUMBER: Z - �z�i P.O. Box 534 '� Fs Hyannis, MA 02601 .CONTACT PERSON: ,nF1d MIDI�fv� Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in qu ntities totalling, at any time,more than 50 gallons liquid volume or 25 pounds dry weight? YES V NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous cha tics and musLb racterise--registered - :_volu Please put a check beside each product that you store: ..Antifreeze (for gasoline or coolant systems) Drain cleaners T Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners . Hydraulic fluid (including brake fluid) Disinfectants 70 qod. Motor oils/waste oils Road Salt (Halite) ,ff fat Gasoline, Jet fuel Refrigerants -5-0 !pm j Diesel fuel, kerosene, #2 heating oil a _ Pesticides (insecticides, herbicides, -1T!z' WOther petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages J Printing ink Battery acid (electrolyte) 1 1a/ Wood preservatives (creosote) Rustproofers T� Swimming pool chlorine Car wash detergents Lye or caustic soda /) Car waxes and polishes Jewelry cleaners �ACY/ Asphalt & roofing tar Leather dyes � Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) J�,�J 1&4Ad— qp Other cleaning solvents So /d, d�cJeoT,e-c Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business 36",70"&85"Tree Spades Brush Chipping. Stump Grindi g m Bobcat-Backhoe-Boom Tru HARRY JOHNSON TREE FARM Since 1920 Specializing in Sales of Larger Size Trees Arnie Johnson 115 Bumps River Rd. 508-428-2234 Osterville,MA 02655 FAX 508-428-3187 TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair 2.Printers BOARD OF HEALTH O satisfactory 3.Auto Body Shops unsatisfactory- 4.Manufacturers PANY �d�+3� '; (see"Orders") 5.Retail Stores COM 6.Fuel Suppliers ADDRESS S Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN= indoors;OUT=outdoors) MAJOR MATERIALSCase lots Undergn IN OUT IN OUT IN OUT #&gallons Age Test Fuels: y-5-1 i�', Gasoline,Jet Fuel(A) 7"15 1C ��a7s" pc esel, Kerosene, #2 (B) Heavy Oils: / ➢� waste motor oil (C) new motor oil(C) 4Tr I�� transmission/hydraulic (—.s Synthetic Organics: degreasers I iqpellaneous:w"k l +_� to � DISPOSAURECLAMATION REMAINS: 1. Sanitary Sewage 2.Water Supply �' I Oct' &A."{d/ wit U.1 0-4—(a.1 if & O Town Sewer )6Public S 0-0}('4 � ,,� VC—On-site O Private d�� , Gv�. 9 ry�..1 •-f a f.0 do ov �'.7r.� 3. Indoor Floor Drains YES NO O Holding tank:MDC_ O Catch basin/Dry well O On-site system / 4. Outdoor Surface drains:YES NO ✓ ORDERS: Q Holding tank:MDC Ma _ f� O Catch basin/Dry well f ►�1. r2>(r i fir>> a,,A O On-site system i l-,S, V ol�a C-c,,,,eA LC_ 5.Waste Transporter Narne of Hauler Destination'", od p YES NO 2. 5r�� &,V�� Z' V �Z Person(s) In6iviewed Inspect Date