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HomeMy WebLinkAbout0070 JOBY'S LANE - Health 70 JOBY'S LANE, OSTERVILLE A= 120 093 ° a Hazardous Materials Inventory Sheet Checklist Date - t2 Physical Street Address-Check database to ensure it exists j' Working Phone Number, —Actual Amounts.-( ie. gas being used.to fuel machines,-thinner to clean brushes-all.count as hazardous.mater.ials;-no blanks)�� Storage Information.-location of,storage,.how long is:storage for? If none; note that:. Disposal Infor nation :.here`andwho? If none;°notethat Applicant Signature:.- wnderstand,what is listed and noted Staff Initial.-any.questions, know who to.ask Vehicle,WashingIRinsing? ._9ive•a vehicle':wash.ing policy and x • - Y . explain if,` ." . - Attach the Business Certificate with your sign offiand comments `*The inventory form should explain.what the business consists of and.the.procedures d.with them: whey are-doing. Notes°need to be left to explain.what youdiscusse ,- YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$40.00 for 4 years). A business certificate ONLY.REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You'must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town. Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: ( ' 0 1 2 OCl 1� Fill in please: �dt: f� rr r APPLICANT'S) YOUR NAME/S: BUSINESS YOUR HOME ADDRESS: - � � TELEPHONE # Home Telephone Number l 3 4-10 Oil s eiu3 � ,-i NAME OF;;CQRPORATION. ., , NAME OF:NEW;BUSINESS` " _, TYPE OF BUSINESS IS THIS A HOME.OCCUPATION? -' YES ADDRESS'OF:BUSINESS . -A l '�`nA ' r MAP .PARCEL' NUMBER �`y"' Ass'essin ) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING 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 e n info =otp rmit requirements that pertain to this type of business. Authorized 19119nature** COMMENTS: i I 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: I w Datelo / q / TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: C BUSINESS LOCATION: 0 INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: O CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: (3� I MO I MSDS ON SITE? TYPE OF BUSINESS: scage, 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 material 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) © Miscellaneous 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 Miscellaneous 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 Miscellaneous 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 (including carbon tetrachloride) ❑ NEW ❑ USED i Any.other.products with-"poison"labels - ___ r - (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash i, WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS A plica is Signature Staff's Initials r --- ;03 PROPERTY ADDRESS:-__70 Jobyl s Lane Osterville Mass . ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1-1000 gallon septic tank. 2. 1-Distribution box. 3. 1-1000 leaching pit • ` Based on my inspection, 'I certify the following conditions: 1 . This is a title five septic system. ( 78 Code ) 2. The septic system is in proper working order at the present time. SIGNATURE: J Name: Joseph-P. Macomber Jr .-- Company:J_P_Macomber_&.Son Inc. 4 10 Address: Box 66 �� -------------------- O�cC 1 _-Centerville ,Mass . 02632 1 -------- ---- Igo , Phone: 508-775-3338 �t 40 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY — RWNM- --. L P. MACOMBER & SON, INC.anks-Cesspools-LeachfieldsPumped & InstalledTown Sewer Connections '66 Centerville, MA 02632-0066 775.3338 775-6412 commonweolth of Mossochusetts Executive Office of Environmental Affairs Department of Environmental Protection Wlllla F.Weld e Trudy Coxe a '. Swetay,EOEA Davld B.Struhs • v c awwWoner SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Address of Owner: operty Address: 70 Joby t s Lane Osterville ,MA. (If different) ate of Inspection: 2 7 9 5 ame of Inspector,. �o�se� Macomber Jr. a Name,Address and Te ep on u b8r. :' Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 508=775-3338 ERTIFICATION STATEMENT certify that I have personally inspected the sewage disposal system at dsbased onddress nd that the my training and information intheepropert(unctionuand nd complete as of the time of inspection. The inspection was p aintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails nspector's Signaturd11#1aW,?4rZ1- Date: f�` Oy 6 he System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this nspedion. 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 he iepon to the appropriate regional office of the Department of Environmental Protection. he original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTE PASSES: have not found any information which Indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 7 Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: 0 One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) Q� The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will'pass inspection it the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ( (revised 8/15/95) 1 FAX(617)55b-1049 • Telephone (617)292.5500 One Winter Street 9 Boston,Massachusetts 02108 • U-3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Jobyts Lane Osterville ,Mass . 02655 Owner: Donna Barrett Date of Inspection:12/7/9 5 B) SYSTEM CONDITIONALLY PASSES (continued) Am Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 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 the public health, safety and the environment. '1) SYSTEM-WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: A]13 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N'Q The system nas a sePUL tdiiic anu buil absorption system and is �, 4hin 100 fee, to a surface water supply or tributar{to a surface water supply. } The system hay a septic tank and soil absorption system and is within a Zone I of a public water supply well. ,D The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. 9V The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: ,�/ 6 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. �Q Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. ,g Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Joby t s Lane Osterville ,Mass . Owner: Donna Barrett Date of Inspection: 12/7/9 5 6 D]SYSTEM FAILS (continued): 4!2 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. d9 Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. At Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped AV /%ny portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Ai Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Ala Any portion of a cesspool or privy is within a Zone I of.a public well. d BJ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: pA The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: /UA 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` bing the sysem adThe owner or operator of any such system shall rconsult thetlocalnregionlaI oty ff cef oflthe Departmentcompliancetforhfurther informationtment program requirements of 314 CMR 5.00 and 6.00. Please (revised 8/15/95) 3 IR SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 70 Joby r s Lane Ostervi i le ,Mass . , Owner: Donna Barrett Date of Inspection: 12/7/9 5 Check if the following have been done: ZPumping information was requested of the owner, occupant, and Board of Health. pumped for at least two weeks and the system has been receiving normal flow rates '�/None of the system components have been e into the system recent) or as part of this inspection. during that period. large volumes of water have not been introduced y Y 2As built plans have been obtained and examined. Note if they are not available with N/A. • The facility or dwelling was inspected for signs of sewage back-up. , The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. ✓ All system components, 4'cluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. , The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. the facility ov.ne; Land occupants, if different from owner) were provided with information on the proper maintenance of Sub Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C' SYSTEM INFORMATION Property Address: 70 Jobyts Lane Osterville ,Mass . Owner: Donna Barrett Date of Inspection:, 2/7/9 5 `LOW CONDITIONS RESIDENTIAL: Design flow: � ^' allons r�'� CM Number of bedrooms: Number of current residents: Garbage grinder (yes or no):A-10 Laundry connected to system (yes or no):1-0 Seasonal use (yes or no): A,10 Water meter readings, if available: I �^ Last date of occupancy:1%_• ` COMMERCIAUINDUSTRIAL• Type of establishment: Design flow: �li__gallons/day Grease trap present: (yes or no)�Ld Industrial Waste Holding Tank present: (yes or no)/L0 n-sanitary waste discharged to the Title 5 system: (yes or no)_�� ater meter readings, if available: C'/1 Last date of occupancy: OTHER: (Describe) s'%1 Last date of occupancy: ti;j} p ' GENERAL INFORMATION PUMPING R ORDS and source of infor Late n: System pu ped as pan of inspection: (yes or no) b If yes, volume pumped r gallons Reason for pumping. lJ7hri — TYPE O SYSTEM Septic tank/distribution box/soil absorption system Xlp Single cesspool Ald Overflow cesspool - A)/-) Privy Shared'system (yes or no) (if yes, attach previous inspection records, if any) Nr Other (explain) ate installed (if known) and source of information: APPROXIMATE AGE of all components, d ��/riaRs OG•� D�`.e-c'i^ cage odors detected when arriving at the site: (yes or no) r 6 5 (revlsed 8/15/95) i 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 70 Joby' s Lane Osterville ,Mass . Owner: Donna Barrett Date of Inspection: 1 2/7/9 5 SEPTIC TANK:Aj (locate on site plan) Depth below grade:1110 /� Material of construction: Yconcrete metal FRP other(explain) Dimensions: Sludge depth: Distance from top c. sludge to bottom of outlet tee or baffle: Scum thickness:_ . Distance from top of scum to top of outlet tee or baffle: C.> Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, a deice of leakage, etc. T shou qQpe gXp;l;y two to three years , �`n�et anc ou�Ie ees alkhRtYll"Eld 60U11U3The septic tan is. structuraiiy sound with no signs of ieakage -No repairs needed at this time . GREASE TRAP:/ (locate on site plan) Depth below grade: A& material of construct ion:,lh,concrete —metal —FRP —other(explain) . l) Dimensions: A14 Scum thickness. Distance from top of scum to top of outlet tee or baffle: D!<tance from botton' of cro-) i.i hot+rim of owier iep or I>?fll�, Al_''/t 1 Comments. (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.j 4 2t( , (revised 8/15/95) 6 i, L. SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSI EM INFORMATION (continued) Property Address: 70 Joby ' s Lane Osterville ,Mass . Owner: Donna Barrett Date of Inspection:12/7/9 5 TIGHT OR HOLDING TANK:Ae (locate on site plan) Depth below grader ,,oaterial of con struaion:/U�concrete _metal _FRP —other(explain) Dimensions:���. Capacity: _gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float ,witehe>, etc I AM DISTRIBUTION BOX t;`= (locate on site plan) Depth of liquid level above outlet tnven Comments Mute 11 lelvi and :;i icjk,ig mo or out of boa, etc.) The Distribution box is level and structurally sound. No signs of leakage in or out of the box. No repairs needed at this time . PUMP CHAMBER: A (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appunenances, etc.) t:ev:sed 8/15;95f 7 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) perty Address: 70 Joby s Lane Osterville ,Mass,. ner: Donna Barrett to of Inspection:12/7/9 5 — IL ABSORPTION SYSTEM (SAS) o to on site plan, if possible; excavation not required, but I may be approximated by non intrusive methods) of determined to be present, explain: e: - leaching pits, number: leaching chambers, number: leaching galleries, number:_S1 leaching trenches, number,length: C-) leaching fields, number, dimensions: overflow cesspool, number: mments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) oam.v sand to medium sand to on in .All ve etation COOLS:�Q cate on site plan) mber and configuration: /4 _ pth-top of liquid to inlet invert: A.11j pth of solids layer: ' pth of scum layer: ' ' mensions of cesspool: 1 d terials of construction: P) ication of groundwater: 11)9 _ inflow (cesspool must be pumped as part of inspection) Il`� mment): (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) I VY: cafe on site plan) terials of construct' n: � Dimensions: /1�� pth of solids: mments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) �A evised 8/15/95) $ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 70 Joby ' s Lane Osterville ,Mass . Owner: Donna Barrett Date of Inspection:1 2/7/9 5 v • SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Town Water s rd C DEPTH TO GROUNDWATER Depth to groundwater: 1 ' + feet method of determination or approximation: Plan on file at the Board Of Health. Town Of Barnstable . (revised 8115195) 9 • 11 . TOWN OF Barnstable WARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTF,M INSPECTION FORM - PART D •- CERTIFICATION �� F•••r^s-r••.-::*-c.,r.....-.--r,m-n•r.:rr:-sr.—,r.-r-cr�-r-•.;--:.—.-r,.--z—*�-*•-•.---rya-.-:F-r+ss=srrs�r.�rrzsr=rm ssn r.•rmr-rrsrm-rrrrr..-rrr r. '. -. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 70 Joby ' s Lane Osterville ,Mass . ASSESSORS MAP , BLOCK ANQ PARCEL # . OWNER Is NAME Donna Barrett 'PART D - CERTIFICATION C NAME OF INSPECTOR Joseph P. Macomber Jr .. , COMPANY NAME J. P.Macomber & Son Inc . COMPANY ADDRESS Rnx hh ne,+Pruri I l P Ma, n2(h�2 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 1 790 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa'1 system at this address and that the information reported is true , accurate , and complete as of the tithe of .inspection . The inspection was performed and any recommendations regarding upgrade, maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: XX(XXXX Systelri PASSED The inspection .%ihich 1, 11ave conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined . in 310 CMR 16 , 303 . Any failure - criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . V System FAILEll* fi The inspection which I have conducted has found that the system fails to protect the public health and the environment in- 'accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Z' h_11L11a'11 Date - 12/8/95 One copy of this ce t.ification must be provided to the OWNER, the BUYER ,(where applicable ) and the BOARD OP' IIEALTII. * �If the inspection- FAILED, the owner or " erator shall u ` P pgrade ' the' eyste�m within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 16 , 305 . 3 �� •- E�t�-• s fC ` � z � W to w THE COMMONWEALTH OF MASSACHUSETTS - DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the - ' ion of Water Pollution Control -®��TOWN OF BARNSTABLE L0'. ATION�,Q .�^I 6� 1,3 SEWAGE # l �3a VILLAGE6-S &///� ASSESSOR'S MAP & LOT �t INSTALLER'S NAME & PHONE NO SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 6- 'Ac (size) !I NO. OF BEDROOMS PRIVATE WELL O PUBLI. WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 3 VARIANCE GRANTED: Yes No s ��� �` �S ��� � ` � � ��' . � w �� �. � � �� _ �, �y � ���� � j C � , .,�;� 15 ' �_ TO OF BARNSTABLE LOCATION e SEWAGE # '"- VILLAGE ASSESSOR'S MAP &LOT/o70 — D 9,9 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1 � Y �m O I, • ASSESSORS MAP NO: PARCEL NO: O 2 No.... .............. THE COMMONWEALTH OF MASSACHUSETTS AP ROVED BOAR® OF H EALTHPOrnlmbleConservation Department TOWN OF BARNSTAB Appliration for Di_qpnaa1 Works Tontuitrart on rprrumm oete Application is hereby made for a Permit to Construct (n/) or Repair ( ) an Individual Sewage Disposal System at: ----...=o.�i�S._. ............................................................ ..... .._re. -j--------- ----------------------------•-------......---......-- - Locatio ddress or Lot No. --- ` o --- .."Y Us --- .:...........•........----------------..... .............................................. W ner Address .... ................ .....•-•-•---••••••...--•-.....---••-•--•••... ----------...------- .. Installer � Address //� . Type of Building Size Lot-_A_'/Y --.-----.-Sq. feet T .a Dwelling—No. of Bedrooms___................ ___-___Expansion Attic ( ) Garbage Grinder ( ) a Other—Type g S1 —-----_---•. No. of persons............................ Showers ( ) — Cafeteria ( ) Other—T e of Buildin ..._. a � Other fixtures .-•-•---•----•-•----•-•----•---•---•------•-----•----•-•--------•--•------•-••-----...... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth.:..._........_. W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area..__....--._........Sq. ft. x Seepage Pit No..................... Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1­4 Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fit Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ 04 ------------------------------------------- •---- ••-------------•••--------•---•-•------------....•-•....•-----------.------------------------•---------•----- ODescription of Soil......................................................................................................................................................................... x U --------- •----------------------------- -------------------------------------------------- -.------------------------------------------------------------- •------------------ .......--------.... W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -----•-••-----•-••-••-••-•-•••••••--••••--•-•-•-•••••---••-•••••••-•---•---••••••-••....-----•••••--•---•----••••-•-----------------•••---••••••----.......-•---•--- ••••---•-••--•••••...-=•-•--•-•••• 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 Compe has been issued by the board of health. Signed ... .... 1� �/� ...... .....I.. ..=-,�� � ..fa��i��'% DareApplication Approved By -----.--. ... -----.Y--�7-----................................................................ Dare Application Disapproved for the following reafons: ...................---- --......... .....------...------------....--. ------........----------- ........................ - - - ------------------------------ -----------.........-------...----------...-------------....----------------------------....---------...............--------- Dale PermitNo. ....... - ..1.3`�---------- ------------------ Issued ......................................................_.--...... Date No.--- Fimic ............�f� a.._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE��/, Appliration for M-nVai n1 Workii TowitrurtWtt ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal t System at: r �- --......... Locatio ddress or Lot No. ....•. 7 ! ? 1_ �. 1` .... . ............................ ............... ........•..........---•-- �/y� O{ ner Address W �-1.-J.... = t -�.�/{ /f ,J......•----^-•- ........... ........................................... Address Installer Q' Type of Building 2 Size Lot_.�_ ___ Jq .......Sq. feet aDwelling—No. of Bedrooms,___. ....................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building-S1_ ........... No. of persons____________________________ Showers ( ) — Cafeteria ( ) PL4 Q 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 ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (? Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W -----•-••----------•---------•--••-•-•--...-•••--•----•-----------------------------••-•..............-•-------•-•••--•-•••.._....---------•-............---- 0 Description of Soil....................................................................................................................................................................... W V ...................................................................:.......................................=-•...................................................._... --------------•--------------- -----------------------------------------------------------------------------------W U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------_........................... .........................................-..............................................................................................................................................••-............ 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 isystem in operation until a Certificate of Compliance has been issued by the board of health. Signed .. . -- .... <t i..._E.112 ................. � � -------------- ---------------------- •� Date Application Approved B Cl �\ .{a�t� � Date Application Disapproved for the following reasons- ---------------------------------- - -------.............-------- ..............................................................-------------------------------- -- ---- -------------------- ---- -------------------------------------------------------------- --------- ......................... q Date PermitNo. ........ -------1 --------------------------------- Issued .-------------- Date THE COMMONWEALTH OF MASSACHUSETTS-- BOARD OF HEALTH TOWN OF BARNSTABLE Tex#if ra e of Gntyliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( �) or Repaired ( ) bYt.. .. . ................. � Y ----------- ------------------- -/ Installer at ................ .. ?.1..-.. r�- t"(........... .. . .. ..........................-----.-------... ......... ............................. �th�e ......- --N...------.. -� •raJc ¢ has been installed in accordance irovisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. ------- -------1_3--',�----------- dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ?7. . ... ---------'-----.. Inspector t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE /f No....9c .-.I: FEE...../.d ......... �r�npk� Permission is hereby granted N !?-s-- ------------------ --------•---...-•--------.... :--•-•--- to Construct (k) or Repair ( aq Individual Sewage Disposal System n at No.........' ,vLcXY p Street q as shown on the application for Disposal Works Construction Permit No. Dated.......................................... •-----------------------•----•-• --- - .. c. Board cf Health DATE........-•--- r ' r•-oa..----------•------------------•... FORM 38E08 HOBBS h WARREN.INC.,PUBLISHERS f � 1 4L .6 N, 77AT F,Fl N J. 3- 4� -i-J 1 ___TA 1L.J.- J'_1-1 4 _V I 6FO54 L T 51DEWQEL ._!_lam L LI; T ----------- A 0 A' !-VOTToM-l- IT: ------- L', J J_ LJ-4 xj Aole­ 7,; In 10 Ilk....... r tH, ',g n-14ARD PE 'S.ULL!l,VAN­ nd. 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