HomeMy WebLinkAbout0068 WIANNO AVENUE - Health 68 WIANNO AVENUE, OSTETtVILLE
A= 141 125
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a
y Commonwealth of Massachusetts
o Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave -
Property Address
Wianno Avenue Realty Trust ,
Owner Owner's Name
Information red for every ation is
requi Osterville / Ma 02655 4/1/2020'
'
page. City/Town State Zip Code Date of Inspection - -
t
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:When A. Inspector Informationf�-�-
filling out forms
on the computer, Sean M. Jones
use only the tab
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspqqtion
use the return Company Name _
key.
74 Beldan Lane
�y Company Address
Centerville Ma 02632
Citylrown State Zip Code
774-248-4850 smjonestitle5Qgmail.com, SI4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system: '
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
4/1/2020
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 has a desigmflow 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 form should be sent to the system owner and copies sentto
the buyer, if applicable, and the approving authority.
Please note: 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.
15lnsp.doc•rev,7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 or 18
Commonwealth"of'Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue RealtyTrust
Owner Owner's Name
information is Osterville Ma 02655 4/1/2020
required for every --
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:. ;` k
® 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:
The property located at 68 Wianno Ave Osterville is served by a Title V septic system consisting of a
1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. Although the system
was found to be in proper working condition at the time of inspection this report does not guarantee
future performance under similar or increased usage.
2) 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 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.
❑ Y ❑ N ❑ ND(Explain below):
15insp,doc-rev.7/26/2018 Title 6 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System'Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wanno Avenue Realty Trust
Owner Owner's Name
information is Osterville Ma 02655 4/1/2020
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cunt.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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 replaced ❑ Y ❑ N ❑ ND(Explain below):
El The system required pumping more than 4 times a year due to broken or obstructed pipes) 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):
3) 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.
a. 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:
t5insp.doc•rev,7rSWI8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust
Owner Owners Name
information is Osterville Ma 02655 4/1/2020
required for every
page. Cityrrown State Zip Code Date of Inspection
' C. Inspection summary (cont.)
❑ 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
b. 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5msp.doc•rev.7/Z8/2418 Tide 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
MEM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust
Owner Owner's Name
information is required for every Osterville Ma 02655 4/1/2020
---- -
page City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
a ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ z Any portion of a cesspool or privy is within a Zone.1 of a-.public water supply
well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50.feet
from a private water supply well with no acceptable water quality analysis.[This
system passes If the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria Indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or lessthan 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 2000 gpd-
10.000 gpd.
❑ ® 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:
5) 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 CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.d=•rev:712MOI8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Palle 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust
Owner owner's Name
information is Osterville Ma 02655 4/1/2020
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for aff inspections:
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))
15insp.doc-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
maim
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust
Owner Owner's Name
information is Osterville Ma 02655 4/1/2020
required for every
page CltyRown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
i'
Does residence have a water treatment unit? ❑ Yes ❑ No
If yes, discharges to:
Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes '❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
t6incp.doo•rev.7/28 OIS Tillo 6 Official Inspection Form:Subsurface Sowaga Diepocal System..Page 7 of IS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust _..
Owner Owner's Name
Information is required for Osterville Ma 02655 4/1/2020
every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment: Office Building
base flow Design d on 310 CMR 15.203): 75 gpd per 1000 sq ft min 200 gpd _
9 ( Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
square ft
Grease trap present? ❑ Yes ® No
Water treatment unit present? ❑ Yes No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available:
current
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
ISirwp.doc•rev.7I28i2018
Title 5 Official inspection Form,Subsurface Sewage Disposal System•Page 8 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust v
Owner Owner's Name
information is Osterville Ma 02655 4/1/2020
required for every -
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
Overflow cesspool
❑ Privy
❑ Shared system(yes,or no) (if yes, attach previous inspection records, if any)
El 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):
Approximate age of all components, date installed (if known)and source of information:
.original system Installed 4/26/1979
Were sewage odors detected when arriving at the site? ❑ Yes No
6. Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints in good condition, no leakage,vented through roof.
151nsp,dog•rev.7/26I2018 Title 5 Official tnspection Form;Subsurface Sewage Disposal System•Page 9 of 18
r '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust
Owner Owner's Name
information is required for every Osterville Ma 02655 4/1I2020
.
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate
cate on site plan):
1.5
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: ................. `
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth:
5"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle 711
10"
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Opened covers and took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurallysound.
t51nsp.doc•rev.7126/201a Title 5 Official Inspection Formr Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments
68 Wianno Ave W
Property Address
Wianno Avenue Realty Trust
Owner Owner's Name
information is required for every Ostetvillia _ Ma 02655 4/1/2020
page. City town State Zip Code Date of Inspection
D. System Information (cont,)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):'
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity;
liquid levels as related to outlet invert,evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explainy
Dimensions: --
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/2612DI8 Tilts 5 Official Inspection Form:Subsurface Sewage Disposal System•Page'1I of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust
Owner Owner's Name
information is required for every Osterville Ma 02655 4/1/2020
page. Cityr town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
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.):
Distribution box was video inspected and was found level and in good condition with no rot.Water
level was even with outlet invert with no signs of past backup.
t5insp.doo•rev.7@tMI8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave _
Property Address
Wianno Avenue Realty Trust
Owner Owner's Name
information is Cisterville Ma 02655 4/1/2020
required for every
page City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc*
" If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain Why:
Type:
® leaching pits number: 1 x1000 gal
❑ leaching chambers number:
❑ leaching galleries number: -
❑ leaching trenches number, length:
❑ leaching fields number, dimensions`
❑ overflow cesspool number.
❑ innovative/alternative system
Type/name of technology:
t5insp.doc riv.7126MI8 Title 5 Official Inspection Farm.,Subsurface Sewage Disposal System Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust
Owner Owner's Name
information is required for every Osterville Ma 02655 4/1/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching consists of a h-20 precast leach pit in parking area. The leach pit was video inspected from
d-box and was found with 6"standing water and a stain line onliy slightly higher. There is no access
cover to grade.
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool'
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp,doc•rev 712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Elm Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust
Owner Owner's Name
information is every psterville Ma 02655 4/112020
required for eve - —
page. Cityfrown Sttatat e Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,.
etc.):
t5insp,doc•rev,7126 O18 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust_
Owner Owner's Name
information is Osterville Ma 02655 4/1/2020
required for every --- -----�
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
r o
C)
Al
AZ Z.8
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63
.117
P
15insp.doe•rev,7I261MIS Title 5 Official hispection Donn,Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust
Owner Owner's Name
Information Is Osterville Ma 02655 411/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
1
P 9 9
Estimated depth to high round water. 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: ®ate
❑ 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:
Groundwater was established by accessing town_of Barnstable groundwater contour maps.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5„sp.doc w.M2612018 Title 5 official Inspection Form:Subsurface sewage Disposal System•Page 17 of is
t Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wianno Ave
Property Address
Wianno Avenue Realty Trust
Owner Owner's Name
information is Osterville Ma 02655 4/1/2020
required for every - — --
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed& Dated and 1, 2,3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
15insp.doc•rev.7126MIS Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page IS of IS
f
• 4
w
Commonwealth of Massachusetts
Executive of Environmental Affairs "r 0
SEC
DEP
Department of �'
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: Cp I —t '
Address of Owner.
(if different)
Date of Inspection:
Name of Inspector: Michael D eD ecko
Company Name, Address and Telephone number: Atlantic Environmental
P.o Box 2384 • M ashpee Ma 02649. Tel : (508) 4771420
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
inspection . The inspection was performed based on my training and experience in the
proper function and maintenance of on site sewage disposal systems. The system
i�. Passes
---- Conditionally Passes
--- Needs further evaluation by the local Approving Authority
---- Fails
Lu
Inspector ' s S ignat t Date: 11 b
The system Inspector shall submit a copy of this inspection report to the Approving
Authority within thirty (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 or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer,if applicable
and the approving authority.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: cog ct%n+,,tzt-3o *41r—
Owners : Svx&�,
Date of Inspection :
INSPECTION SUMMARY:
Check A,B, C, or D
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the
failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are
indicated below
B) SYSTEM CONDITIONALLY PASSES:
--- 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 determinate (Y,N, or ND). Describe basis of determination in all
instances. If "not determinated",explain why not.
---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or
exfiltration ,or tank failure is imminent. The system will pass inspection if the existing
septic tank is replaced with a conforming septic tank as approved by the Board of
Health.
---- 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
H ealth).
----- 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address : fob W`mm'aNt:> aJ�
Owner :5 ojek
Date of Inspection: I i kk%\Ct6
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health , safety and the environ-
ment.,
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:
---- Cesspool or privy is within 50 feet of a surface of water
---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small
marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT.
-- The system has a septic tank and soil absorption system and is within 100 feet to a
surface water supply or tributary to a surface water supply.
---- The system has a septic tank and soil absorption system and is within a Zone I
of a public water supply well.
---- The system has a septic tank and soil absorption system and is within 50 feet
of a private water supply well.
---- 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 analy-
sis 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 notrogen is equal to or less than 5 ppm.
D) SYSTEM FAILS:
-- 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 cor-
rect the failure.
--- Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool.
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:—.-s"c A,5
Date of Inspection: 1 It t za6
D) SYSTEM FAILS (continued)
-- 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 over-
loaded or clogged SAS or cesspool.
--- Liquid depth in cesspool is less than 6" below invert or available volume is
less than 1/2 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 Soil Absorption System, cesspool or privy is below the high
groundwater elevation.
--- Any portion of cesspool or privy is within 100 feet of a surface water supply
ortributary to a surface water supply.
---Any portion of a cesspool or privy is within a Zone I of a public well.
--- Any portion of a cesspool or privy is within 50 feet of a private water supply
well
--- Any portion of a cesspool or privy is less than 100 feet but greater than 50
feet from a private water supply well with no acceptable water quality ana-
lysis. 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Wk��--
Owner:Qakk
Date of Inspection
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above :
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 :
--- 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.
The owner or operator of any such system shall bring the system and facility into full compli-
ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00.
Please, consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: (P
Owner.CAS
Date of Inspection:l t �
Check if the following have been done :
-x Pumping information was requested of the owner , occupant and Board of
Health.
•-x None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during the period. Large
volumes of water have not been introduced into the system recently or as part
of this inspection.
--x As built plans have been obtained and examined. Note if they are not available
with N/A.
--x The facility or dwelling was inspected for signs of sewage back-up.
-•x The system does not receive non-sanitary or industrial waste flow.
--x The site was inspected for signs of breakout.
--x All system components,excluding the Soil Absorption System,have been
located on the site.
---x The septic tank manholes were uncovered, opened and the interior of the sep-
tic tank was inspected for conditions of baffles or tees,material of construc-
tion, dimensions,depth of liquid, depth of sludge, depth of scum.
---x The size and location of the Soil Absorption System on the site has been deter-
mined based on existing information or approximated by non•intrusive methods
--•x The facility owners and occupants if different from owner were provided with
information on the proper maintenance of Subsurface Disposal System.
SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: LZ U -Marro 1V".
Owner: gbCS
D ate of I nspection: r S
RESIDENTIAL:
Design flow: gallons
Number of bedrooms :
Number of current residents:
Garbage grinder (yes or no) :
Laundry connected to system (yes or no):
Seasonal use (yes or no) :
Water meter readings, if available:
Last date of occupancy :
COMMERCIALANDUSTRIAL :
Type of establishment:Design flow : '(S gallons/day
Grease trap present: (yes or no) tv�_,
Industrial waste holding tank present (yes or no) :
Non-sanitary waste discharged to the Title 5 system (yes or no) : ti:
Water meter readings, if available : tok .
Last date of occupancy :_k_kZ_C i
Other: (Describe) ............................................................................................................
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
SyS� .►'!'1.... . .... ......... .............
System pumped as part of inspection(yes or no) :...�0..........
if yes, volume pomped : .................... gallons
Reasonfor pumping :............................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 613 &.3rRNNo k1 ,
Owner:
Date of inspection:
TYPE OF SYSTEM
KSeptic tank/distribution box/soil absorption system
- - - - ... Single cesspool -
-- Overflow cesspool
--- Privy
-- Shared system (yes or no)(if yes, attach previous inspection records, if.any)
--- Other (explain)...........................................................................................
APPR OXIMATE AGE of all components,date installed (if known) and source of information
. ...........ls. { ........................................................................................
................................................................................................................................................
................................
Sewage odors detected when arriving at the site : (yes or no)......�,.�
SEPTIC TANK : . ��5...
(locate on site plan
Depth below grade: .��-....
Material of construction: ...k concrete ......... metal ........ FRP ........ other (explain)
.................................................................................................................................................
Dimensions:Vx5 .5
Sludge depth :....0........
Distance from top of sludge to bottom of outlet tee or baffle:.......�....................
Scum thickness :...0..............
61
Distance from top of scum to top of outlet tee or baffle: ..............?. ...................
Distance from bottom of scum to bottom of outlet tee or baffle :...... .b:'..........
Comments :
(recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid
level ela 'o to outl t yert,structural int t eviden a of le k e, tc
V. .. .... .. .. +ems_
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: G8 �1 13 NO �
Owner:
Date of inspection:
GREASE TRAP: .....
(locate on site plan) _--
Depth below grade: ...............
Material of construction: ........concrete.........metal........FRP........other(explain)....
..........................................................................................................................................
Dimensions:...............................
II, Scum thickness:........................
Distance from top of scum to top of outlet tee or baffle:.......................................
Distance from bottom 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, evidence of leakage, etc.)........................
................................................................................................................................................
................................................................................................................................................
TIGHT OR HOLDING TANKS:.......
(locate on site plan)
Depth below grade:...............
Material of construction:........concrete........metal.........FRP..........other (explain)..........
................................................................................................................................................
Dimensions:............................
Capacity:....................gallons
Design flow:...............gallons/day
Alarm level:.............................
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
................................................................................................................................................
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: fa23
Owner: gt-t cus
Date of inspection:
DISTRIBUTION BOX:....
(locate on site plan)
Depth of liquid level -above outlet invert:.:5�94:"'l -
Comment:
(note if level and dstributi n equal e ' ence f 'ds carryover,
... .... ,..... ... .... t. . . . . .
evpid c.,'1.f .lea fa into
ut o ox, etc.).. ... .. ...... .. .
.................................................................................................................
.
PUMP CHAMBER:..............
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)....................
................................................................................................................................................
SOIL ABSORPTION SYSTEM (SAS):...l�-G ....
(locate on site plan, if possible; excavation not required, but may be approximated by non-
intrusive methods)
if not determined to be present, explain:
.................................................................................................................................6..............
.................................................... ...........................................................................................
Type:
leaching pits, number... .�X,l"o..Pi`t
leaching chambers, nu m r:........
leaching galleries,number:...........
leaching trenches,number , length:.....................
leaching fields, number,dimensions:...................
overflow cesspool, number:..........
Comments:
(note dit' of soil, igns of h raufic ailure, le I of ponding, co 'lion f vegetatio
�. r�. .ts..
etc,),
t tl.
.�... t. fU...... ...
.�O
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address:
Owner:
Date of inspection:
CESSPOOLS:....46.
(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: .....................
Indicator of ground water: ....................
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
PRIVY: .....W..
(locate on the site)
Material of construction: ...................................
Dimensions: ......................
Depth of solids: ................
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,
etc.).
................................................................................................................................................
................................................................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address : b$ '""''NOZ
Owner: .S1-held-s
Date of inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'
63-a-
2
4-ox G
DEPTH TO GROUNDWATER:
Depth to groundwater: }aO.feet
Method of determination or approximative:
................................................................................................................................................
................................................................................................................................................
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S� NAME & ADDRESS
of �
- o ,
B UILDE R OR OWN &
v�&& .
DATE PERMIT ISSUED _ �.A _ �9_:� �_
DAT E COMPLIANCE ISSUED
�_
� �
4
6.® `_
cT�� �'^.
;,
No....... � ..�-----FR$.�5 a. ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD�g HEA Thy .
'j........0 F...... .......................
App iration for Bigpviial Worko Tnnuitrnrthin thrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System a
� t:...- A X.. .......... ........................................... .................................
Location-Address _ r Lot No.
Owner Address
? �- l
---------- --- ---
Installer Address /�
dType of Building Size Lot----Z�_ 0....Sq. feet
U Dwelling—No. of Bedrooms______________________________ __ _Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building0_�e.1Ce__ No. of persons_______ Showers — Cafeteria
Other fixtures -- ------_-----------• -•---•------------•---.....--•--•----•--•---•---•-•--:----•--••---------••----•-�3)---•----•-•---•----•-•-(•-�-1-
W Design Flow____.___...�._�3_____________________gallonsi per day. Total day flow........... _ ..................gallons.
WSeptic Tank-LLiquid capacity__ X0gallons Length............ Width._.�j.__...... Diameter________________ Depth................
x Disposal Trench—No____________________ Width__ ....... Total Length............... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter_____ ----------- Depth below inle ........�....... Total leaching area_7Z.__. ....sq. ft.
Z Other Distribution box ( Dosing ank
Percolation Test Results Performed.by,_ ..1 �__.____ ` _ ____________________ Date...r...............................
as Test Pit No. 1.........I......minutes per inch Depttl of Test ` It
`2.______ Depth to ground water..... __________
(i Test Pit No. 2.........(......minutes per inch Depth of Test Pit____-1.:�•-...... Depth to ground water.-_. ______________
a -------------
jl�
Description of Soil . ............. .. .Z °'..---'`-z-- 1Z----- � � �._.__...
P
U ------•------------------------------------------ .............
---------
.....-------------------------
•------------------------
•--------------
•----------------------------------------
W -----•-•-•-•-----------------•-••-•------•----•-----•-•--•---------------------------------------------------------------------...-----------------•-------•-•-----------------------------•-•--•-•-•--
VNature of Repairs or Alterations—Answer when applicable-----------------------------------------7.....................................................
•--------------------------------•-•-----------------------•--._...--•••-•----•--•-•-•--•-•------•••-•---------•---••--------•--•-•----•••--•-------•-•-•-•---------•-•---••---••._.....-----•--_---•--
Agreement:
The undersigned agrees to install the.aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE 5 of the State Sanitary ode— The undersigned further ag�ees not to place the system in
operation until a Certificate of Compliance has be issued b of heal .
Signd_. _...- ... ---- •--•----- -- •...........................
Date
Application Approved BY ....:....:....• �r 2'� -
Date
Application Disapproved for the following reasons---------------•--------•----•-••----------------------------------------------------------------...........----
•-----...-•..................•-•-••-------•-----------••---•--•--•---•----------•••-•---•-------••-•---------•-•----••-----------•-•------•-----•-•------------•------------------•----•------•...._..._
7 Date
PermitNo--------------------------------------------------------- Issued-----------.............................. .......................
Date
No.._ YR .............. o��...
`y THE COMMONWEALTH OF MASSACHUSETTS
BOAR® !-IEA T
Appligjtvn„fur Disposal Works Tnnstrnrtiun Vrrmit
Application;,is"hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: .
� lt. �
L tion-Address r Lot No �
P,
.............. . t ..........................
Owner Address �
;Installer Address a
dType of Building Size Lot..._....4.a ___..Sq. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons........_.,................ Showers — Cafeteria
p I o"..,Other fixtures -------------- = .
d ----
---------------------
W
Design Flow.......... .................!`_gallons per day. Total daily flow.......... _. a ..................gallons.
WSeptic Tank—Liquid capacityAW.gallons Length-----K....... Width.._ V------ 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 (40< Dosing tank ( )
~' 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........j.......minutes per inch Depth of Test Pit---- Depth to ground water.... ...............
O Description of Soil.... -------- ...�r............. .. . .................. ---
x
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 Sanitary ode— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued byrtho h agd�of heal r. _,
Sigd - ................................
s1fi Date
Application Approved By----- . �. .
Date
Application Disapproved for the f oll,owing`reasons:; ........ ......... ............................................................ ... ................
t
..............................................................._•:_--......-------••--------------------....---•-------•---------------------------------------------•--------------•---•------------
' rt Date
PermitNo. ..... ..•-- Issued-.......................................................
l
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH t
.................O +............................................
(I�.Ta
riifiratr of f omplianr�
TH S R. Individual Sewage Disposal System constructed or Repaired ( )
b3 -- ------------- gait ---•---
at.A.1....Vi "alled
� �: f ---
has bee in accc"ance with the provisions' T ` f The State. Sanitary Code as described in the
applicatio or Disposal Works:Construction Permitto ___.- . 2__�. dated------ -_ ..`........
r+
THE UANCE OF THIS,CERTIFICATE -SHALL NOT BE CONSTRUED AS A GUARANTEE.THAT-THE .
SYSTEM 1LL FUNCTION SATISFACTORY
t f�
DATE... ••. .. .- p: .
._._7..._ , ....... Ins ector .
THE COMMONWEALTH OF MASSACHUSETTS
u BOARD HEALTH
............OF.. :Y
No......... .......... FEE. ......
` ��tl � nrUan rruti�
Permissionr� is hereby granted"^-. - -- --•------19- --- '.............. ..........._._..
to Construct (d ) ep it (/ ) an Indi u Se�� Da al Syst
at No.. --1 2 l/ �;�/ •.... �! :; f= •. j ................
Street
as shown on the application for Disposal Works ConstructioAP �• o . ............. Dated. -2.,� .....71.........
............................
5 Board Pom
e
DATE.......
....... ----- .... .........................
r--.._.....--•..............................
a: '
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS -'
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 Fl. 367 Main St. "H annis MA 02601 Town Hall and et the Business Certificate that is
P Y ( g
` re uired b law:q y
DATE:
�� Fill i please: ,
s ,M
APPLICANT'S" YOUR NAME/S: ► ► 1 d 1A �1�-�C_ 1_ -F- C) OS A
Q
INESS YOUR HOME ADDRESS:
H x LEPHONE`# Home Telephone Number
NAME OF CORPORATION: j;
NAME OF NEW BUSINESS S TYPE OF BUSINESS � 1r e�V t C.
IS THIS A HOME OCCUPATI N? YES NO l 1
ADDRESS OF'BUSINESS �� W� 'N I ��. ?�2tD'LAP/PARCEL NUMBER E- � �I [Assessing)
When starting anew busiress.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-inobtaining the,information you.may need. You,MUST GO TO 2D0 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 g informed of permit requirements thatpertain'to this type of business
- Authorized Signa ure*
COMMENTS:
2. BOARD OF HEALTH'
This individual has".been" r d f the permit requirements that,pertain'to this type of business.
L aryI �1
T Authorized Sign ture**
COMMENTS.:.,
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has"tie for" t e licensinglrequirements that pertain to this type of business.
m
r..
t
" Authorized Signature** y
COMMENTS:
-
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