Loading...
HomeMy WebLinkAbout0208 CRYSTAL LAKE ROAD - Health 208 Crystal Lake Road Osterville P A = 139 047 1 Apr 26 2012 4: 34PM HP LRSERJET FAX p. 1 s q CLEAN SURFACE DELZADING , INC . 203 Essex St . (781) 340-0816 Weymouth, MA 02188 F'ACSIMSLE COVER SHEET DATE: Apr. 26, 2012 TO: Director, Asbestos S Lead Program. (617) 626-6965 Director, Childhood Lead Poisoning Prevention Program (781)774-6700 Board of Health, Town of Barnstable (508)790-6304 FROM: Mark S. Bianco RE: Notification of Deleading Work �208 Crystal Lake Rd. , Osterville, MA PAGES: 3 Rpr 26 2012 4: 34PM HP LRSERJET FAX p, 2 COMMONWEALTH OF MASSACHUSETTS Department of Labor&Industries and Department of Public Health NOTIFICATION OF DELEADING WORK All sections of this form must be completed in order to comply with the notification requirements of M.G.L. Ch. 111,§ 197, 454 CMR 22.00 and 105 CMR 460.000 as most recently amended File Number: (AGENCY USE) Contractor performing project Mark S.Bianco License#DC 001055 Lead Paint Inspector John MacIsaac License#I R 2378 Date of Inspection 3/26/12 If low-risk deleading work is being performed,complete the-following line: Property Owner: N/A Agent: Address of Project Building Name (if any) Floor Street Address 208 C e Rd. Apt. No. 4 City Osterville Zip 02655 Deleading Method: Qr—<Y—S—cr�apbg Heat Gun Caustics Liquid Encapsulant Covering Demolition Replacement Other If"Other" selected,please explain Check One: Dwelling is multi-family Single family X Start date 4/26/12 Completion date 517/12 When will work be done: A.M. XG P.M. Weekends X Project Supervisor's name Mark Bianco License# DC001055 Property Owner Casey Birtwell Address 208 Crystal Lake Rd. City Osterville State MA Zip 02655 Telephone (617)921-4446 In case of emergency contact Mark Bianco Phone: day (617)340-0816 evening(78l)340-0544 (over) Rpr 26 2012 4: 34PH HP LRSERJET FAX 7 p. 3 Page 2 of 2 In accordance with Massachusetts General Laws C.I I 1§197,454 CMR 22.00 and 105 CMR 460.000,notice of the date and method(s)of emoval or covering of paint,plaster or other accessible materials containing dangerous levels of lead is to be provided and must be received by the following agencies,at least 10)days prior to the beginning of deleading. NOTIFICATIONS MAY BE FAXED. - 5 1. Department of Labor,Lead Program,Dlvlsion of Occupational Safety % 19 Stamford Street,1"Floor,Boston,MA 02114 FAX: 617-62fi-6%5. 2. Director,Childbewd Lead Poisoning Prevention Program Department of Public Health,Donovan health Building,S Randolph Street,Canton,MA 02021 FAIL: 781-774.6700 3. Occapantaofdwelliog unit 4. All othereccupents of the residential premises,if any ' 5. Local Board of HealtblCode Enforcement Agency 6. Massachusetts Historical Commission; (if premises are listed on the State Register of Historic 220 Morrissey Blvd. Places,this notification must be made upon receipt of an Bodon,MA 02202 Order to Correct Violations or at least 30 days prior to FAX(617)727-5129 initiating preventive deleading) NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY,DATED AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY THE DEPARTMENT OF LABOR&WORKFORCE DEVELOPMENT. PROPERTY OWNER(If owner or unlicensed owner's agent will be performing low-risk deleading work,complete the following): Property Owner Agent(s) Address Telephone Number (____j• „ I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control Regulations.105. CM R460.175,for ownedagent low-risk abatement`and containmern: 1 further certify that 1 or my agent will be performing the following low-risk activities (I have circled all that apply): . applying liquid encepsulant capping baseboards removing doors,cabinet doors,shutters 3 applying exterior vinyl siding covering surfaces I certify that all the information contained in this notification is true and correct to the best of my knowledge end belief Date sign Revised 12I2007 Y w. From:Jennifer Cullum To:"Town Hall 6:47:69 PM 4282012 Pagel of 1 Now selling Please Please call ESPRESSO 508-775-0621 PFUO ' to order EN ,- We deliver! 11-2 BATT AR& SPECIALS April_27,_2012 �r 1, �ruaf Salad! 3eqq Goat 'Cheese Sal dI 6.qq /1 prosciutto,honeydew melon, 2 �A�•�ils ar�� a�a�a�I �o�'� Green leaf lettuce with P y n, '%a greek pizza-Served with a.mixed green salad!, gent chase,and walnuts! rang �' , � 'ar�ir�all 6oq ;rt #p C� Lean and rare roast beef with Dijon,ina o. With basil pesto mayo,t*roccoli,roastexl red Nll horseradish cheddar cheese,sauteed mu•hrooms poppers,roasted tomato,red onion and havarti cheese! and caramelized onion an a ciabatta roll! Pepperona f anwi n l 6, n1 9s Pra rt ! ,6.qq „ With pepperoni,roasted red bell pepper posto,shredded 'Roast beef with Chi at]e Chicken, .� mozzarella and cheddar,roasted red bell pepper and ee w p pepper Colby,, baby spinach bacon,chipotle Mayo,tornato and onion with lettuce;on FltInch &! 6. a wheat wrap! Wide garlic herb ere-am cheese,lettuce,tomato,onion on speAtIa hicketh •�� 63-9 a toasted roll with a ride of au jus.belish! Lemon pepper chicken with provolone,with tomato, lettuce, onion,cucumbers and carrots on a'spinaah wrap Odium oh,Who wii.l>basil.pesto mayo' With yummy crispy chicken cutlet,shredded cheese, ch"*A000k ch,*Ackth raha F1,t 16ogq' cucumber,roasted red bell peppers,tomato and sprouts Wit1.t q?tw boars head chicken,clti)otle Mayo, swiss on a bed of green leaf lettuce! cb.00so,roasted red bell peppers and baby spinach 1t &J badgn! 6>qq grilled Panini style! With pastrami,roasted red bell peppers roasted red bell pepper mayo, swiss cheese,tomato and spinach on a I�arzEaa�si�we �� �� �� �'ar�traao�4�� wbite wrap-grilled Panini style. Spi:cv boar's head turkav with.Alrler lean cheese, caramelized onion and bab •s inach with chi otle ayv� .h, i 6agq y p �- macro on a Panini! With freshly made tuna,lettuce,tornato,onion,avocado and sprou#4 in a spinach wrap,• #Wla Tuna Melf! 6. q 3 ana' l2ift Quitr ,n 6'qq 'With.swiss and,American,avocado,bacon,and yummy -Served.with a mixed green salad! tuna-toasted on marble rve. Londonport roast beef with?pepper Colby jack With melted l esh mozzarella,garlic roasted tomato, cheese,roasted red bell pepppe-r mayo,lettuce, baby spinach and roastW red bells-grilled Panini style tomato,sprouts and riPasted red bell peppers in a with garlic olive oil! Vs.■ppw]�i!�n.a.ch wr�ap■y■�7!�{ y, ■1V (/I� �J^/Y■� /�l�+ q �eg7y J¢/�'1aJr �61{ ,;"��y■ �r■� ®) .. Y ��� cfVIPd L+ 0 YO i 32UM attj a Half!: 3.q it AWN / 6Pgq 0 *Captain Parker's Clam Chowder Everroast chicken with bacon and havarti.cheese,basil r 2,tUarrn Chili pesto mayo;roasted red bell peppers; lettuce,tomato and `" onion in a wheat wrap • Creamy Tomato Tt>r:as LQ Chicken and 16ce A whole gilled cheese with tomato Grilled roast beef with sweet baby ray's bbq sauce bacon and cheese in a toasted roll!Delish! � .. R TOWN OF BARNSTABLE . BOARD OF HEALTH / ARTICLE 11: MINIMUM STANDARDS FOR HUMAN HABITATION Date V Time: In Out 00 Owner51v�- �-7 Tenant Address c Z� ( � Address �� 0 Y o h Complia Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities �0 MDmved _- 3. Bathroom Facilities LU ` 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation = 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use _ 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 3 I q 2, 19. Number of Tenants Observed d Tu PART If 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) -5 c Person(s) Interviewed Inspector If Public Building such as Store or Hotel,/Motel specify here rt ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE:OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION q yJ� TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A MAP �....�-3 CERTIFICATION PARCEL Oil Property Address:. `� P��. LOT L3 ,Ll Owner's Name: Ann.) Owner's Addr s: 11=� sz yo Date of Inspection: aada. a,ama RECEIVED Name of Inspect r• plea a print). fbe—�'3< 20f' 04t, APR 1 .0 2002 Company Name. '��}lG� Mailing Address: 10 OQCO TOWN OF BARNT ., HEALTH DEPT. / Telephone Number: S0 R°'7-7/•!6 2 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 ection 15.340 of Title 5'(310 CMR 15.000). The system: Passes Conditionally Passes Needs.Further Evaluation by the Local Approving Authority. Fai Inspector's Signature: �r Date: L9o�. 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 ofthe 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 ****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 6/1.5/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property P y Address: Zo � a O-OW J Date of spection: Ucdea ada, Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D y lvi ,,:A - stem Passes• ? ,1 SAC; ""k"-"have not found,any information which>indicates'that any of the failure criteria described in '310"CMR. !..! I5:303,�or..in_3,l-0'CMR 15,304 exist.Any failure criteria not evaluated are indicated below. i n , 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,wilI 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 abroken;settled or uneven distribution box. System will pass inspection if(with. .approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is.leveled or replaced ND explain: The system.required pumping more than 4 times a year due to broke_n 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: 2 Page 3 of 1.1 OFFICIAL INSPECTION.FORK-NOT FOR VOLUNTARY`ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: CPGO ,4 Owner: Date of ection: c D_. 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. L- System will pass.unless Board.of Health determines-iwacco.rdance with.310 CMR 15.303(1.)(b)that the system is not functioning in a manner which will protect public health,safety an ttie environment: _ Cesspool or privy is within 50 feet o.f 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 aseptic 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 feetbut 50 feet or more from-a:- private water supply well". Method used to determine distance x "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 I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: g �GC% Owner: . Date of pection: Ck, 4aka D. System Failure Criteria appiieable 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 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 J watersupply. 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 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.] 1J (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. Large Systems: To be considered a large'system he 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 ofa-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 15.364.The'system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM } PART B , u s � . CHECKLIST Property Address: Owner. „ a Date o pection: ® y •J 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 VWere.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 T ~ Were as built plans of the system obtained and.examined?(If theygwere�not available'note as N/A) Was the facility.or dwelling ns ected for of sewa a back u T.7 9 "} �— Y g i P signs g P • . 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 scuni 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 informaiion.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 approxtma. of distance is unacceptable) [310 CMR 15.302(3)(b)]" 5 Page 6 of 1] OFFICIAL-INSPECTION-FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: o o �Coa� Owner: Date of pection: b . FLOW CONDITIONS RESIDENTIAL' Number of bedrooms(design). . Number of bedrooms(actual): DESIGN flow based on 310,CMR 15.203 (for example: 110 gpd x#of bedrooms): ' -Namber of current residents: ( Does residence,have.a garbage grinder(yes'-or no) Is laundry on a separate sewage system (yes or nQif yes separate inspection required] Laundry system inspected es or no�Q— Seasonal use: (yes or n y Water meter readings; rfayatilable(last 2 years usage(gpd)):00 It 7" 01—6Z- Sump pump(yes or.nQ�_ ti Last date of occupancy: 6-< COMMERCIAL/INDUSTRIA1-/),�4— 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 rro): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records ', Source of information:. Was system pumped as Part of the i specti .(yes or no): If yes,:volume pumped: gallons--How was quantity pumped determined? T Reason Tor.pumping TYPE F SYSTEM eptic 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 copyof the DEP.approval _Other'(describe): proximate age of all components,date installed(if known)and source of information: Were sewage odors'detected when arriving.at the site(yes'or no -- • Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFO.RMATION(continued) Property_Address:�0' Atio-'4'a/ 10-k- Owner Date 0 spection: 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:V(locate on site plan) Depth below grade: Material of construction: oncrete_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: (1`X S Sludge depth: � Distance from top of sludge to bottom of outlet.tee.or baffle: Scum thickness: p 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: `la Comments(on pumping recommen a�" tions,i let and outlet tee or baffle condition,structural integrity, liquid,levels as related to outlet invert,evidence of leakage,etc.): 44'u4z� GREASE TRAP�K__cate on.site.plan) 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 of last 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 VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :PART C SYSTEM INFORM A�TION(continued) Property Address:.&Z6r-' ("./V" U`�e4� Owner: ( Date spection: TIGHT or HOLDING TANK tank must be pumped at time of ins pection)(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: Comments(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:-I� Comments(note if box is level and distribution to outl qual,any evidence of solids carryover, any evidence of 4eqkage into or out of box,etc.): PUMP CHAMBER (locate,onsite 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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION,FORM. PART C t SYSTEM INFORMATION(continued) Property Address: �4 % Owner- -Date o spection: � ,c;J c�00oZ SOIL ABSORPTION,SYSTEM (SAS):. locate on site plan,excavation not required) If SAS not located explain why: - Type leaching..pits,number:_ leaching chambers,number: aching 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. : CESSPOOL �(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 or no): s Comments(note condition of soil';signs of hydraulic failure,levei of podding,condition of vegetation,etc.): PRIVj,&k(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 SYSTEM INFORMATION(continued) Property Address: P Y o Q Owner: Date of 1 pection: . �WQL . 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. o -33 ° 10 Page I I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: ©8 6, 9040( Owner: Date of spection: SITE EXAM. Slope Surface water Check.cellar, Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from 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 you established the high ground water elevation: .� 11 Permit Number:' Date: Completed by:. HfGH GROUND-WATER LEVEL COMPUTATION Site Location: �� �� / � Lot No. Owner: AAO 1& Address:. Contractor:_ (f/� ® ® Q�7,9,0?�, Address Notes: STEP 1 . Measure depth:to water table to nearest.1/10:fi................................. .... Date month/day/.Year STEP 2 Using.Water-Level.Range Zone w and Index WeIIMap:locate site and determine: A Appropriate index well.. ............................ :............ �1��Q Water-level range zone .............. . STEP•:3::. Using,month ly.report,,."'Current - Water Resources Conditions" determine current depth to water level for index well ........................... month/year STEP. 4 Using.Table.of-Water-level Adjustments - for index well (STEP 2A)„current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) ` determine water level adjustment ............ (�.................... ........ STEP:. 5 Estimate depth to.high water by subtracting the.water level adjustment.(STEP 4') from measu.red:.depth to.water level at site (STEP 1) ............ :....................................................................,............................... Figure If I--Repradueible Gomputation form . r • V � • _ !, - • �J1��r�yfs� l�� !�1 _ ; r 4�. • j .. • �� .<�. r 1:`' ` TOWN OF BARNSTABLE f(LOCATION (,r��� Ke.��• SEW AGE4 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE,NO. eo, o A-8v&w)_ ydE3-s64o SEPTIC TANK CAPACITY LEACHING FACILITY (type) Zii (size) 3 NO. OF BEDROOMS o2 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: Fi VARIANCE GRANTED: Yes No . / . �a ��1 j� ,�� . _ 3 =fin�/Tr.���s' ` „f boar' i o_ � -i - «` 3 ;-3 �^� � ��� �-a � � ��� �_,� ��` �� �� � � �-�= �2 ' 7 FEB...... ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Application is hereby made for a Permit to Construct ( ) or Repair (/�an Individual Sewage Disposal System at: /� I �-gQ.Zn n_.".._ � CryT�1� �e!cn�. °`,; Lr:. .... l' Location-Address or Lot No. ............... U !�^ASt� .................. ... .......•.... -•--....-•-•--------....----••---•----.....-'-----^_..........'--•......•......................_. i Owner Address a �QRlan��-w.... __�...-•---•----'........---•••............ ..•---......_._.._-••---•-•-- •...............................•••.._..... ..............•.. In aller Address d Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder .( ){ Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' 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 ( ) aPercolation Test Results Performed by-------- ---------•-----••-.........•••----------'----......----•-•------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fX4 _ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ --------------------------------------------- •---------------- •............ ........ .-.----------------- •---------- ••-._...---...._...... ...... 0 r Description of Soil---.......-•-•.................•----....-•-•--------•--.....'-•--------•'---•-•-----------------------'-------•-•••---•-----•--•------•••...._............--•--....:..•. x . s xp ..... .................................................... U Nature of Repairs or Alterations—Answer when applicable____. f.e. ..S�'.s���?_..__--__--_ !I>T o.`..__.._... ....... 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 h board of healt . Signed .V% ..7.... p .. ................................... ...........- ................ -----. Dare Application Approved By ...........1��\ --- ................................................. ......Aft Dace;1_e_ �3 Application Disapproved for the following reasons: ...................................... ... .......................................................................................... ........ ........................ . ....................... . ................................................................... . ............................................. .. ...................-.................... qqQ� Dare PermitNo. ..............[....�J V.... ................. Issued .............. ......... . ..............----- -..... Dare A. OV7 No..=�• :. f�y V FEa......3.r....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di►ipinial Works Tontitrnrtinn Permit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ` 1 '$S2. a..��9 i1.il.:...: QL1 C��.?l rt�Lt'ilf:I(�i- t�;, (r-�1I ••--•••-----•-----•---•--•-•-----•---•----••-----•------•---•-........•....----- Location-Address or Lot No. ...............:�L't�..:_ ..................................................... •••-•--------------••--------••--••---....-----•-••-------....._....A.-----•••-•...........------ 1 Owner Address W ..................... 1:.�.::.:_�...�:.•l/I1. �:: Installer Address d Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building --------------_-.----.---- No. of persons----------.----------------- Showers ( ) — Cafeteria � ) a' 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. 3 Seepage Pit No--------.-_-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) •" Percolation Test Results Performed by-------- -------------•••--•••-••.......-----------------------•-•----••-• Date......................................... aTest 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........................ a ---•-•----------------------------•---•-•-•----- ----------•---------....-----...-----•-----•-••------..._.....---.....•-•-••-•-•----•---•.....•.-..._.._.... 0 x Description of Soil-----•.............•---•----•--•---...--•--•------ i V ----------------••-----••---- ----------••-•-........--••••--•--•--••-•-•-•-----•••-•--........---••------------------------------•-•-----•----•..........--........................................ W •-----•----•-------------- ..................................................................................... .._.. ..s.- ....................................................... —Answer when applicable......Nature of Repairs or Alterations 1. �a.._S ,S��'�?...................... ....................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the Iliovisions 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/hF board of health. .....--------------------------------- --�T:�.-l.�`!F ApplicationApproved BY ..............( --- .................................................................... .......lQ 1t Application Disapproved for the following reasonf: ........................................................................................................................................ ...................... .................................---.............------....................---....................---..................---------------..........------.......................... ........................................ Dare Permit No. ...................D....:......5_5.. Issued .................................................:.................. Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cnerr#ifirate of Tontyliance THIS IS TO CERTIFY; That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ''_.:-:. .,.:.,. .. ............................... .. .............. 1 Incrallcr .... ......... - -...-------------..._.._........._.__.......--..............._...................................._................................... 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 CONSTRUE15 AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector .- ----- •.. .... .... ._.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 99 TOWN OF BARNSTABLE No._.1. FEE....................... �i rn 1 urkii (funntrnrtion Permit Permissionis hereby granted.------_------•-- -----•--------•-------•------••----•--•--------------•..............••----..................•--...............-•-...... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo.......................................................................-----•---=-------•---------...... . ------------------------------------------------ ------------------•-•............. Street // FFQQ��'�/ as shown on the application for Disposal Works Construction Permit No. .__'_1�.7_. Dated........................................... ............................ ........ .......................................................... G DATE..............l_ �------------------------------ <_1 Board of Health ...iK__:..�:�--:-G FORM 36508 HOODS&WARREN-INC..PUBLISHERS