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HomeMy WebLinkAbout0194 CEDAR TREE NECK ROAD - Health 194 Cedar Tree Neck, R� A=076-002 I►7 d S it on COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS N� DEPARTMENT OF ENVIRONMENTAL PROTECTION i yV� TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1gq, C4AV- Owner's Name: ID.-,ri,:c; 1.3 e(I A hd c r. r . Owner's Address: S to rv, e As agoVQ 1ILLEAi[I Date of Inspection: / /A /c,e C EC 1 2 2000 Name of Inspector: (please print) 0 n N J�-Awgrm; Company Name:'j2oN's Ctic,ti.�,ri Mailing Address:,.-) Lri f�,cti c e �A- Telephone Number: Y'7 7 — O 1 '7 �? 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 Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 1114 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving ,authority. Notes and Comments ,,,s-(nal( A)-C,-j cQ19 4-, ****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 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: lyy cer)ArL- J-ne--� /I/eclC 11,D Owner: r Date of Inspection:1a /a O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with- approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND.explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a su_rface 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 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: a 3 Page 4 of 11 Y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: lqV Cevkti- -rh-ee Ive ck 61� .r L Owner n - t Date of Inspection: cr D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or iclogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool _ 1/ iquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow �ReRequired pumping more than 4 times in the last year NOT due to clogged or obstructed r e s .Number q P P� g Y gg P�P ( ) of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] 4 0 (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 the 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 of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "Yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 .;Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ffi( cP/J/l.Ir, hi ecic rth-eF h 0 Owner: Pnitio C?e& Date of Inspection: a.l� Check if the following have been done. You must indicate`yes"or"no"as to each of the following: Yes No _, /Pumping information was provided by the owner,occupant,or Board of Health /Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ✓ — Have large volumes of water been introduced to the system recently or as part of this inspection? V _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) v _ Was the facility or dwelling inspected for signs of sewage back up? vl 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? JC 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 o 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(3)(b)) 5 I r Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: j y c+e/)Ak. Aj QQ(C"bL-Q'k_nv Owner _ e.(f/4 n•'i Date of Inspection: 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): 30 Number of current residents: Does residence have a garbage grinder(yes or no): W O Is laundry on a separate sewage system(yes or no):N U [if yes separate inspection required] Laundry system inspected(yes or no):ALej Seasonal use: (yes or no):yD 7— Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):to Last date of occupancy: T !( U e c u 1 ve c.Q COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): �pd 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 no): 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 inspection(yes or no): If yes, volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: 7OF SYSTEM ptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate pge of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: PV CedA&4A� ee N E r-k ILA Owner:'��� � Date of Inspection: 1;1 Lab 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:_(locate on site plan) Depth below grade: _l Material of construction: A,-Concrete_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: O Sludge depth: C) Distance from top of)fudge to bottom of outlet tee or baffl Slot e - Scum thickness: / A Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee gr baffle: (� How were dimensions determined: >�e Y�j.vn­fk Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate 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 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): 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: y Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): g f ,,Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C-e-✓JA& `_I<AQ-e- w G c-(C Owner: 04Z4- r Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number:-�L5w -�l (4tv a4—pti f leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.): 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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 n OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1jq Ce-Opw4n.eg ky:4K(1D Owner 0A Date ofInspection: _ j / Go SKETCH OF SEWAGE DISPOSAL SYSTEM i 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. G/�i � 1 G 9 i 10 „Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) J n-Le— Property Address: y c- /Ru. &e c:lc kO Owner:Q ” I fS1A M on:Date of Inspecti UCH 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: v seObtained 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: t_-"C"hecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: l �'° e c ��-to� /S� b c..s.•► 4.� e°.� 1vu J'fJ��( r S �e / L�PtJA U" /Se40f a �f Co 4t 11 I ®® -)L No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes / PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01ppYfcation for Df5poal *p5tem Construction Vertu Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. fi?Y Ce VjAIL ' n 2 e �!R C Owner's Name,Address and Tel.No.r Assessor's Map/Parcel 06-o — M �l�(, ��(y►��, t ` 4 m Y Installer's Name,Address,and Tel.No. U 'go ((6 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 c) 62 gallons per day. Calculated daily flow gallons. _ =Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -CAA��ct' S f /� 6,5 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this BRard of Hea Signed Date --312 a Application Approved by Date 3.6 Application Disapproved for a following reasons irmit No. Date Issued i , � No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pprfcatfon for Xh5pogaf *proem Con!6tructfon J)ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. lC L/ Ce 0A p n,e I (j.t C(C Owner's Name,Address and Tel.No.. Assessor's Map/Parcel 076-691- jVl W t y► v R f ( ` A ryX y Installer's Name,Address,and Tel.No. P 'R o v t/6 7 Designer's Name,Address and Tel.No. RO/i S &ZA UA4�ti n�nl SAC Type of Building: 2 i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures I Design Flow 3 O y gallons per day. Calculated daily flow f gallons. Plan Date t Number of sheets Revision Date ' Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -C I 1, co r G U . 64 / +_n_ty K 0 Sc t Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with theprovisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t is B d of Hea Signed Date -319 0 Application Approved by !4 ^ Nn Date 3 -X Q--�1 Application Disapproved for.the following reasons Permit No. 1 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( Upgraded( ) Abandoned( )by t at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - /& dated Installer Designer The issuance of this permit shall n t be construed as a guarantee that the system will function as designed. Date Inspector 1 1 V � �P �— " !�z ---------------------------Fee ��© C 8 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS 1wf5pooar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair Upgrade( )Abandon System located atT_�'r� .emu A! fil M and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to 'comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit.--- Date: �, — ��� $ Approved by 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) s hereby certify that the application for disposal works construction permit signed by me dated �' , concerning the property located at_ Lq �z Q A � �� �, �J 2 C I� meets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed • There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) �M�h ay�d SIGNED: � �✓ DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert \ i y t TOWN OF BARNSTABLE LOCATION r aAn I r\* 2 UFC SEWAGE # VILLAGE_ 1W4AJ-`! ( I It n ASSESSOR'S MAP& LOT 57 6 Do INSTALLER'S NAME&PHONE NO. f�OiU ,C=/" A-:C,— SEPTIC TANK CAPACITY LEACHING.FACILITY: (type) ` �1 (size) 2 0 NO..:OF BEDROOMS- BUIi. ER OR OWNER 11 /M� PERMITDATE: 3-2a- `�� 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 Furttished by x fC . I 1 r ��y ( i Massachusetts Department of Environmental Protection 100342797 BWP AQ 04 (ANF-001) y� ; Asbestos Project# � Asbestos Notification Form r Project Revision r Project Cancellation A. Asbestos Abatement Description 1.Facility Location: RICHARD PINKOWiTZ 194 CEDAR TREE NECK RD Instructions 1.All a.Name of Facility b.Street Address sections of this form BARNSTABLE / must be completed in MA 02648 6174802357 order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification RICHARD PINKOWiTZ OWNER requirements of 310 CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: FRONT SIDE OF ATTIC Standards(DLS)notification i.Building Name,Wing,Floor,Room,etc. requirements of 453 2. Is the facility occupied? r!a.Yes rib.No CMR 6.12 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner-occupied residential property of four units or less)? r] a.Yes r b.No MassDEP Use Only 4.Blanket Permit Project Approval,if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: Approval ID# 6.Asbestos Contractor: AIR SAFE INC 71 NORMAN ST UNIT 13 a.Name b.Address EVEREfT MA 02149 9783395361 c.City/Town d.State e.Zip Code f.Telephone A0000464 h.Contract Type: r 1.Written r 2.Verbal g.DLS License# 7. JAIME E AMAYA AS060847 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8 MATTHEW RYAN SCHREIBER AM900542 a.Name of Project Monitor - b.DLS Certification# 9 FLI ENVIRONMENTAL INC AA000144 a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 4/1/2021 4/1/2021 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 7AM 4PM NA c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11.What type of project is this? (j a.Demolition r b.Renovation r c.Repair [i d.Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 Massachusetts Department of Environmental Protection 100342797 BWP AQ 04 (ANF-001) F Asbestos Project# Asbestos Notification Form r Project Revision r Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): r! a.Glove Bag r b.Encapsulation r c.Enclosure r d.Disposal Only rii e.Cleanup r f.Full Containment r g.Other-Please Specify: 13.Job is being conducted: r a. Indoors r,:. b.Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 120 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation e.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j.Insulating Cement VERMICULITE 120 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15. Describe the decontamination system(s)to be used: THREE CHAMBER DECON 16. Descri-:)e the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): 6 MIL POLY BAGS 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18.Do prevailing wage rates as per M.G.L.c. 149, § 26,27 or 27A—F apply to this r a.Yes Roil b.No project? Revised: 11/13/2013 Page 2 of 4 Massachusetts Department of Environmental Protection 100342797 ``10k BWP AQ 04 (ANF-001) # Asbestos Notification Form Asbestos Project r Project Revision r Project Cancellation B. Facility Description 1.Current or prior use of facility: RESIDENTIAL 2.Is the facility owner-occupied residential with 4 units or less? r' a.Yes rl b.No 3 RICHARD'PINKOWITZ 194 CEDAR TREE NECK RD a.Facility Owner Name b.Address MARSTONS MILLS MA 02648 6174802357 c.City/Town d.State e.Zip Code f.Telephone 4 RICHARD PINKOWITZ 194 CEDAR TREE NECK RD a.Name of Facility Owner's On-Site Manager b.Address MARSTONS MILLS MA 02648 6174802357 c.City/Town d.State e.Zip Code f.Telephone 5 NA NA a.Name of General Contractor b.Address NA MA 11111 1111111111 c.City/Town cl State e.Zip Code f.Telephone NA g.Contractor's Worker's Compensation Insurer NA 12/31/2021 h.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 1827 1 a.Square Feet b.#of Floors Note:Temporary storage of Asbestos C. Asbestos Transportation & Disposal containing waste 1.Transporter of asbestos-containing waste material from site of generation: material is only allowed at the place rl a.Directly to Landfill or ri b.To Temporary Storage Location/Transfer Station of business of a DLS licensed Asbestos contractor or a transfer AIR SAFE INC 71 NORMAN ST station that is c.Name of Transporter d.Address permitted by MassDEP and EVERETT MA 02149 9783395361 operated in e.City/rown f.State g.Zip Code h.Telephone compliance with Solid Waste Regulations 310 CMR 19.000 2.If a temporary storage location/transfer station is used,list name of transporter of asbestos containing waste material from temporary storage location/transfer station to final disposal site: SERVICE TRANSPORT GROUP 301 OXFORD VALLEY RD SUITE 803B a.Name of Transporter b.Address YARDLEY PA 19067 2673999411 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection 1100342797 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r Project Revision 1 r Project Cancellation C.Asbestos Transportation&Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: AIR SAFE INC 71 NORMAN ST a.Temporary Storage Location Name b.Address EVERETT MA 02149 9783395361 c.City/Town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA LANDFILL MINERVA ENTERPRISES,INC. a.Final Disposal Site Name b.Final Disposal Site Owner Name 8995 MINERVA DRIVE c.Address WAYNESBURG OH 44688 3308663435 d.City/Town e.State f.Zip Code g.Telephone Note:Contractor must sign this form for DLS notification purposes A Certification DFW DFW "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PRESIDENT 3/18/2021 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) all attachments and that, based 9783395361 AIR SAFE INC on my inquiry of those 5.Telephone 6.Representing individuals immediately 71 NORMAN ST EVERETT responsible for obtaining the 7.Address 8.CityTrown information, I believe that the MA 02149 information is true, accurate, and complete. I am aware that there 9•State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment. The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4 /LING` + i ,?k-c-P 1 17,7 5� ��_ ;��----�. 1 9 i `�,r v r y. �� � � -2Y 6-� r � � ,..�.. 1 TOWN OF BARNSTABLE +/ „LOCATION � CtQ p� -Me-k &X-CeSEWAGE # VILLAGE f¢h Jp! ( [f' ASSESSOR'S MAP & LOT 576 -Da'1, INSTALLER'S NAME&PHONE NO. = 9011 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 2 0 '�l f-� NO.OF BEDROOMSAZ BUILDER OR OWNER { A'1 /Ell t, a� t PERMITDATE: 3-1t"/ `f COMPLIANCE DATE: w 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 d.y.wetlands exist within 300 feet of leaching facility) Feet Furnished by $ i D z f,cAq s ii No--------- ------------- Fas. ................... THE COMMONWEALTH OF MASSACHUSETTS ;� tl►�14i/ BOARD (;q= HEALTH 7P ------ --------- I A firation -for Dig oilat lVadii Towitrurtton Vrruift Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ` ocation- ddress �. � or Lot No,��. e f ........................... ..... ...- .._._..._.......__ ........................ er w ress ................. I taller - Address Q Type of Buildi - Size Lot_______________________-_-.Sq. feet Dwelling X No. of Bedrooms...................._.__._"._.__..__._.__.Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) • "`✓' ...----�----------------- Other fixtures __.._.___. ............... W Design Flow.___.___q 1 allons per person per day. Total daily flow.__.__._____ --••• g P P P Y Y •�---- --------------- ---gallons. WSeptic Tank� Li uid capacity/ Ilgallons Length................ Width-------.-------- Diameter-------.-------- Depth.____-_-_.._--. x Disposal Trench—No..................... Width __-` I p ta .;/:__f�6_ Total leachinggarea-----------------..sq. ft. Seepage Pit No.._.._._�.._..__.. Diameter___ ______________ e th el Art _'_�...:. . Total le cl 'll trea.___.__._._.____..sc. ft. Other Distribution box ( ) Dosing tank ( ) - 1 2�j�� " Percolation Test Results Performed bY......................................................................... Date--------------------------------------.. a Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water._.-_---_.__.__..-.-_._- fX, Test Pit No. 2-----_----------minutes per inch Depth of Test Pit---------_---------- Depth to ground water__._-----___-_-___._.__. W -----------••--• .......................'.--------..................................................................................................... 0 Description of Soil------ •--------------------------•---------------------------------------.... --------------------------------------------------------•------------------------ 4 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 Article NI of the State Sanitary ode— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Wen • ed by the beard of alth. .......... � c .-!/... D to Application Approved B " " , 'c PP PP Y ... . Date Application Disapproved for the following reasons:.................................................................................................---•--------- --•••-....--•-------------------------------------------------------•-_.._-------•-••-••-----••-•-•-•-••-----•----•-•-----•-----......_•-•-----•--- ................................................ -dl Date Permit No. Issued...//..�/(a��- ...-------- Date .r }t • •---------------------------------------------------------------------�-___ NO._ ........... Fps.. .................. . THE COMMONWEALTH OF MASSACHUSETTS ` BOARD Of HEALTH t3 �(r -.......OF........ _It 4 ---- ---------- Appliratinn -for Bigpuiittl darks Cnoto4rnrtinn Urrmit Application is hereby made for a Permit to Construct'(il000r Repair ( ) an Individual Sewage Disposal System at: t a lion dress .............................or Lot Now,,. - ..................... t W oc r ess . • -------------------- $, - ..I aller Address FType.of Buildi Size Lot............................Sq. feet U Dwelling' No. of Bedrooms_____________________ .-_-___._Expansion Attic: ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons---------------------------- Showers, ( ) - Cafeteria ( ) Q' Other fixtures --------------------=--------- - - --------------------------- ---------------------------------------- ---- ---------- 1. W Design Flow__ ______________ ..__ gallons per person per day. Total daily flow----.--_--- ___..:..._..-.....__gallons. IXSeptic Tank�Liquid capacity/gallons Length---------------- Width................ Diameter................ Depth---------------- IX Disposal Trench No. .................. Widtl __.____-____ P t'` Lea�gth Total leaching area-.-.-----.--.-_--._sq. ft. Seepage Pit No.-----_ Diameter_._ e t el t Total lea' lino, rea... b ------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) *�- 21 Percolation Test Results Performed by....... ------------------------------------------------------------------ Date:---•-------------------------------.-.. a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...----._-_.-.--_-..... (i Test Pit No. 2................minutes per inch.. Depth of'.Test Pit.................... Depth to ground water...................... -------------------------------------- --------=-------------•-------------------------------------------------•---•----------------•-•--•-------------------- D Description of Soil == ---- - ------------------------------------------------------------------ -- U W ---•---•--•--------------------------------------••---------------------------------...................................................................................-----------•------------------- UNature of Repairs or Alterations—Answer when applicable._.-............................................................................................ ----------------------------•----------------A------=------•----••-•-•---•---------•------••------•-•-•----•-------•-•-•--------• •-------•-----•-•--------•---------------------- --------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary ode— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has n ipmed by the bRard"of h _ = • ! Zaite <APPlication Approved BY ---•• Application Disapproved for the following reasons:........................-------- ...........--------------•------=......................................... ---------------------------------------------------------------------------------•--..-.•.----------•--------------- ......................-------------- -------------------------------------------- Date Permit No:•••••--••---=........................................... Issued......... Date THE COMMONWEALTH OF MASSACHUSETTS J; BOARD OF HEALTH .......... ♦'w ...........OF...........,�,��-...................�/"..`............. T.rrtifirntr of 01,11mplianrr TH , CERY/ 7Y,ta0e Idual Sewage Disposal System constructed ( or Repaired ( ) by.....r . I. U;�------r.....",--*e,---------;.... staller ,, fj , at ..........R....j........... -------------- has been installed in accordance with the provisions of Article XI''of The State Sanitary Cod as escribed in the application for Disposal Works Construction Permit No..................:..7---------------- datcd....-1:/1__ 7 THE ISSUANCE OF�THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL UNCTIO SATISFACTORY. DATE-----------I 7 / -.._-____---_-----•--_ Inspector----------- ------- THE COMMONWEALTH OF MASSACHUSETTS y BOARD O HEALTH OF..... ... ��J4 'S... ..:� � �r.. .. ..... . ....... No.__----•-- r FEE _ %spolial k,I (IT ZA Ovit rrrmit .10 Permission is hereby granted-._-._ . - ---- -- �--- C -------••------------•---••-••-•••••--- If to Constr ct �40e pair ( ) an Ind vidu S age Sal Sy em f�� at No.--- - .....+W------• Street ' as shown on the application for Disposal Works Construction Per NO.4_ BoA®rd�,i,,, 11 ated``--��j 4... .7-.x.............. = ism�"'�►- ---- DATE L . ealth FORD 1255 HOBBS & ARREN. INC., PUBLISHERS - ' ._ --,� i �, � ' (� . . r •. 1 . . .. �� ,' �, l , vV S � . � . . �, f r �� �. .�-- -� . '. . , i , _ . •. � ' : , 1 _ 5 � t _ ��