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HomeMy WebLinkAbout0046 CHOPTEAGUE LANE - Health 46 Mopteaguo4M A Marstons Mills 1 s YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 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.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) v- - -,:�,�au�" "�", 1.- DATE: � G�� Fill in please: " ?M Aa'* * � APPLICANT'S YOUR NAME/S: 'c C�"f� ) w BUSINESS YOUR HOME ADDRESS: h D u �� G,�. n s Da TELEPHONE # Home Telephone Number SO - 3 7- 1 SSs1 ' NAME OF CORPORATION: NAME OF'NEW BUSINESS D N cr TYPE OF BUSINESS- Gja�i IS THIS A HOME OCCUPATION? NO ADDRESS OF BUSINESS L16 C,kapa.....' l can r��5 �v�5yh`lls lM9 MAP/PARCEL NUMBER 0 0� �d 7 L� (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street)'ao make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE . t'p This individual has been informed of any permit requirements that pertain to this type of-business. Authorized Signature*,* COMMENTS: 2. BOARD OF HEALTH This individual ee �edofth rmit that pertain to this e of business. MUST COMPLY WITH ALL P type MATERIALS REGULATIONS y�'AZARDOUS Authorized Signature* COMMENTS: 3, CONSUMER AFFAIRS En ENSI G AUTHORITY) This individual has inf ed f e licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: TOWN OF B STABLE ',!",OC ATION 43�6J2 VeQ alol e0 SEWAGE # AGE Crrsr�� z22-z, ,� A/S/SESS 'S MAP&/(LOT o�� &PHONE NO.�/ 7�d/06�7 �fl SEPTIC TANK CAPACITY A006 LEACHING FACILITY: (type) / ' GJ (size) NO.OF BEDR t BUILDER OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: 7 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 3 t of eac �/fac" ' ) A1 Feet Furnished b /�, • r s �t lull TOWN OF BARNSTABLE -ATION �1 ��� G yi . SEWAGE # l VII.LAGE ,/�1-5 744 /�i l�S ASSESSOR'S MAP&LOT OZ�a INSTALLER'S NAME&PHONE NO. ���� � �o�S ����/� y� A SEPTIC TANK CAPACITY �- LEACHING FACILITY: (type) f 7' j (size) NO.OF BEDROOMS BUILDER OR OWNER y�¢� �,5 okou p PERMITDATE: �— $' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �S� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) V,4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �ear� OI l � ,/ TOWN OF BARNSTABLE LOCATION 44 SEWAGE# 4 VF-LAGE ( /� // A/jSSSESSO 'S MAP &LOOT: 7fL SCi"t3R MMERLNAME&PHONE NO. SEPTIC TANK CAPACTTY"O q2 S2f, 6 6 LEACHING FACILITY: (type) 7"� C/ (size) NO.OF BEDROOMS-3 BUILDER OR OWNER iO PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist. within 300 f of�}}eaich-i�gg fac ) Feet Furnished by /�7t9/0 �l co,,�,evl-lGYJ, -:27/C' �� K� - �,�. � ' Si f �+ O 4 >a�,, 4 OF �i �� t No.� FIz$....��a............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ap.pfiratiou for Diipuial Wurku Towitriar#iun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (pQ an Individual Sewage Disposal System at: AV •. ------------------•---------------•-•-..... - ------------------------------...... /Location-Address or Lo J.. off' o v t o.4/q ; V � 4n r i'r� ...: •...................... ---- --------------------................................ -•---- < Owner Addres G.r...l s.� ►�rrJ--------� --......f'1 N--- -.------^ `M ------------------------------------------- - ------ Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms-----------------------.___-__--__-----.--._Expansion Attic ( ) Garbage Grinder ;JID aOther—Type of Building ____________________________ No. of persons-------------------:-------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- -- W Design Flow............. ..................gallons per person per day. Total daily flow.._--_-_-_--•4�.......... WSeptic Tank—Liquid capacity/��....gallons Length----- Width________________ Diameter---------------- Depth......�Y..�T x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------/......... Diameter-----la-`----- Depth below inlet.....X•_---___.__ Total leaching area..................sq. ft. Z Other Distribution box ( %4. Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date-------................................. Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ fZ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 9 ........................................................................................................................................................... ODescription of Soil........................................................................................................................................................................ x U --•------------•••-•------------•-----•-----•-------•----•-••----•----------•---•-• ----------------•--•----------------•---------•----•--••••--•--•----•----•---------•------•-----•--•---•-•--..•----- W U Nature of Repairs or Alterations—Answer when applicable- ----.--4e __ ._.�!`J 3 - -------------- G A✓ � .. . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian as been ' by the board of health. �t Signed ............ ------------ _... ... .... � ----- De lication Approved B -vt ------------------ --- -------------------------------------------------- e �tion Disapproved for the following reasons: ................................... ............................................................... .. ................ ...... - --------- ------- -------------------------------------------------------------------------------------------------------- ---------------------------------------- No. ........L2_ Issued ...........�.`...�.�.�....�� Da�e --- -- ---------- d 24_z97y V THE COMMONWEALTH OF MASSACHUSETTS t i BOARD OF HEALTH TOWN OF BARNSTABLE f Appliratinn for Di-nVnnttl Wnrk,i Towitrnr#inn Vamit Application is hereby made for a Permit to Construct ( ) or Repair (K an Individual Sewage Disposal System at: V C�(��U�% '4 v� L v�1 r T,�,s rv► �� �.tN� E1� y is ........ ...........•--........... .-•--- ----.....-----------------------•-- .r--..... ....--------------------------•-•-----•-••------ --•-----------•---•-----•-----------...... �. Location-Address or Lot No. .1 d1�Ct�'= (J >�V cv i i....................................1'T �ILQ t1 ...................................................J D tGsr '1 = /�! z! Ivl r L46 Owner Addres UU ----------------------------•----------- -•---------•------------•--------•-------•-----------•._746— -------------•••-•--•----••---•------------•-•-•---•-•--------.......... ...... Installer Address d Type of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms.......................................-----Expansion Attic ( ) Garbage Grinder (—)nJ 0 `4 Other—T e of Building No. of ersons---------------------------- Showers a YP g�---------------------------- P (----)--- Cafeteria ( ) dOther fixtures ------------------------------------------------------•------------------••---------•-- -----•----------•-. ------ W Design Flow...........75�.......................gallons per person per day. Total daily flow------- -�i�C) ............gallons. ---- Depth------ W Septic Tank—Liquid capacity�U00...gallons Length...-.<� - Width..5--..... Diameter......-.--- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------/--------- Diameter._.../ :_`_..... Depth below inlet.....X........... Total leaching area..................sq. ft. Z Other Distribution box ( ,a) Dosing tank ( ) Percolation Test Results Performed by....... --•-------•-•--------•--••-----•-••-•-------•----•----•---•----•-- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit...............----. Depth to ground water......................-. fi Test Pit No. 2................minutes per inch Depth of Test Pit.._......_-._--._... Depth to ground water........................ a --•-----•-•----•..................•••---••------•--•------••-••------......--••------------•-................----------------•-----•---....----....----..---. 0 Description of Soil........................................................................................................................................................................ U ................................._.............--------------............------------••----•.......•-----••-----------•--••..............•---------.......................f............................. W UNature of Repairs or Alterations—Answer when applicable^...�_-4_._C_?_,6../------4e.0.- L �!:w....P1.!=._.._W.�( Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complianfceelhaassb been /is ued by the board of health. Signed ..r(/L�'G✓.. --1..--.. '�........................................ -------- ---------J-- Date 1 Application Approved B Application Disapproved for the following reasons- ----------------------------------�---------------------------. .---............---------------------------- �% Date Permit No. 9 /.0F f Issued ........... Date `''.........�/. ......... _._--------_----"u"---_v—` ------i—`THECOMMONWEALTHOFMASSACHUSETTS f I. BOARD OF HEALTH TOWN OF BARNSTABLE Gex#ifi a e of Tomplinurr THIS IS TO CERTI , That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) C�✓� �l_.Q)� C.�L/mil- iL�U c�_r CVV by ---------------------------------------------------------- --^4�'-----------------------....------------ --------...----......_ InscJlcr at .....- ...... _.. (o f: -G��7- f -`��.... ---(/-w�.�...........//111 .-.�...-------1 l.tS has been installed in accordance with the provisions of TITLE 5 The State Environmental Code as described in the application for Disposal Works Construction Permit No�."<-_���_..�... � dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------ ..`"... V ........ .._.- Inspector ...... V THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` TOWN OF BARNSTABLE No./,�J'.. ZJ FEE---��...-..... Din110nttl fkn Tnnitrurtinn "rrmit cr a c_ 7 CL"iS-1"��o� '� Permission is hereby granted-----------------------------A.-y--•----- c�;----------------------------------------------------- to Construct ( ) or Repair ( an Individual Sewage Disposal System) atNo.--`•••••-•--•-•-•••-•--••-•••----•------�4;......... -11. "s_..... 1`,-1�.....----414 -`---- .�1 +-------------------------- Street as shown on the application for Disposal Works Construction Perm' 4Z 6.__�%ated._.--r--- ..�.-4....!�.,� --•------•-- o Board of H alth DATE------ ti?-----•----------------------- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS 1 Y J 'e. &7- dI A F �� • AR/V.ST� �P I 51 E- /f, 2S S� ° S� h ivy 4 o T 8 _ Lo/ zfq z7 \ y9 n BED �Rcen 47 � h f \\ 47 • T 48 t7 c5 CA � � / •. ���p�1AL SgN�r I Q�ln / or JOHN °- Z 9 � JACOBI No.814 U PERCAPE•ENGINEERI .. `P.O. BOX 616 E. SANDWICH, MA 025 362 F o A BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop Date of Inspec} �7S Ma td 2 $, arcel 7 Owne(-T� PART A — CHECKLIST — AUG 2 8 199- CHECK IF THE FOLLOWING HAVE BEEN DONE: ✓PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALT E w NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT B UCED THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. 49 5 d/ AS—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. !/ THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK—UP. THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. yJ v THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE, DEPTH OF SCUM. THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON—INTRUSIVE METHODS. (/ THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL /� 12 No of Bedrooms (3_—No of Current Residents V Garbage Grinder _Laundry Connected to System _/�—Seasonal Use NON RESIDENTIAL: -- - Calculated flow WATER METER READINGS,IF AVAILABLE: GALLONS Pumping Records and Source of Information: / SYSTEM PUMPED AS PART OF INSPECTION? Q IF YES,VOLUME PUMPED = GALS Reason for Pumping: TYPE OF , STEM: Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared,system (if yes,attach previous inspection records, if any) Other(explain) App oximate age:of all components. Date installed,if known. Source of information. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC Depth below grade: Dimensions: S/ ! , S / Materiel of construction: Concrete Metal FRP Other} (� Sludge Depth // Distance from top of sludge to bottom of outlet tee or baffle 33 Scum Thickness C9 /i ----[Distance from Top of Scum topp of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle St2m ants• `en Dz r �/ / DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: ' I PUMP CHAMBER: Pumps in workin g order? Comments: SOIL ABSORPTION SYSTEM (SAS): IF NOT PRESENT,EXPLAIN: TYPE: — Qv Comments: Si / / KJO ^ CESSPOOLS' Number and configuration Depth—top of liquid to Inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: 01 PRIVY: Materials of construction Dimensions Depth of solids Comments: `SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS:WITHIN 100' . o 5b DEPTH TO GjROUMDWATER: DEPTH TO GROUNDWATER METHOD OF'DEr W.INATION OR APPROXIMATION: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA (Indicate Y. yes N-no ND—not determined.Describe basis of determination.It"not determined',explain why_not) Backup of Sewage into Facility? Discharge or pontling of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? . , Liquid depth in del, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? Is any portion of the SAS,cesspool or privy,below the high groundwater elevation? Wdhm 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone l of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS __,STATED IN THHE"FAILURE CRITERIA'SECTION OF THIS FORM. t/ 1'1' AVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA'SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATES ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(d applicable),APPROVING AUTHORITY am gk' - a'�,��??kka MA�44c ti Tt'ryr s .k`.,x"•^'.r�t�§'.S'�. Si'y''s'"--^�P "e'{ a, Pi a -' }r�ta'b .G: sx ,r1t'-:4, .fin` £�� SSESSOR'S MAP NO. '!,' PARCEL LOCATION SEWAGE PERMIT_ 1).� iLlAGE I N S T A LLER'S NAME i ADDRESS S U I l D E R OR ' OWNER ace-�A Ac swe S DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� r t� _ _ _ __ �, � � _ �. _W� +� ' J �� (�® �� 6 q .. ��� ��� �� ,��,, R �i d' �2�n �j Fx ............. ..... THE COMMONWEALTH OF MASSACHUSETTS r BOAR® OF HVLTH ...................OF.. /. . ._.-....-................--..__........_..-..._....._.... ,��r lira Ilan for Di u tt1 urk 'nstr ion Permit Appli tion is hereby made for a Permit to Construct ( Vf or Repair ( ) an Individual Sewage Disposal Sys .. ._ . _ .............. -- ---- .... ..--•---------------------------• ---•- - Locati Address or Lot No. --... .— •- --------- ------ --------------------------------•-• ..........•-............................................................................-_-__..... Address = e----------------------------------------- --•-•-----•••----•----------------------------.......... .�-------------•--........ M Installer Address Q7i Type of Building , Size Lot-_____,._ ...........Sq. feet FaDwelling—No. of Bedrooms.__ •-Y Expansion Attic (� Garbage Grinder 0) -1 _.._ L .......__ - aOther—Type of Building .........................."No. of persons............................ Showers ( ) Cafeteria ( ) Otherfixtures ..•••••--••..................•••----•--......-••------....•••----••......_........_._...._..._._..........-----...-----.......................--__-•-- W Design Flow..............4. ...................gallons per personC�er ay. Total dail flow........�_ ..............____.___._ ons. WSeptic Tank—Liquid'capacit/.M..gallons Length__! ___ Width�__-__Y_.... Diameter................ Depth_ ...... x Disposal Trench—No..................... Wi h...._ __._-___.. Total Length___......_. ....... Total leaching area......... _. .. sq. ft. Seepage Pit No._6�0�__._ meter _ll Depth ow inlet_......... Total leaching area_ _ _.sq. ft. Z Other Distribution box (. Do nk WPercolation Test Results Performed :. ...... ......................................................... Date_ _. .._ ........_-_. Test Pit No. L__.° minute er i Depth of Test Pit... ___ Depth to ground water-. `�_._____..--. f4 Test Pit No. 2................niin es pe €, Depth of Test Pit.................... Depth to ground water........................ .............. ••-•....................•---......_._._......--••-._....-------------•----................................................................. 0 Description of Soil...................... V ------------------------ ---------- •---•------------------------------------ .... -------------- •--------------------------------------------------- ----------------------------------- ------•----- W UNature 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 Code—The undersigned further agrees not to place the syste in operation until a Certificate of Compliance b issued the board of health. e � ��....------- ................. �fB //^^ Date ApplicationApproved By--•--•••-•- ---------••. ...................••-•-• ._....... _ ......... .. PD. _ D e Application Disapproved for the fo owing reasons____________ ________________________________________________________________________________ ------------__ ................................................................................................. ................................................................................................... Date PermitNo......................................................._ Issued......................................................-- Date s � 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H LTH 01, ApplirFation for Disposal Works �(bustrurttun �rruti� Application is hereby made for a Permit to Construct ( `or Repair ( ) an Individual Sewage Disposal Syst ........• ......................--.......................................................................... n 2 f11 Locatiq Address' or Lot No. pp .J � t Address .......................................... ... ^ ..........................• ......• Installer Address Type of Building Size Lot y. ---------..Sq. feet Dwelling—No. of Bedrooms.--, ............I..........................Expansion Attic (Ahl Garbage Grinder ) 04 Other—Type of Building .... ............... No. of persons............................ Showers ( ) — Cafeteria ( ) ti ' ................. • . ...... ....:..:..-----.....-----------------................:_...._......---------•--------....... Design Other fixtur ----a ....g._. . .. p-•P_----.• • ay. Total dail flow........ ............................. ns. Septic Tank—Liquid capacityf _..gallons .Length._.._.: Desl Flow.............. ..�..,.. gallons per erson�er ' ----_-- Width,`�P..-__-�----- Diameter................. Depth-- ------••---- Disposal Trench—N�................. Wic"t_._..__.....___._.. Total Length--._.______......_. Total leaching area........... .. .. sq. ft. Seepage Pit NO... s✓ __.____.. meter _ ..� Depth below inlet........... Total leaching area_ : -?. .sq. ft. Z Other Distribution box ( Do nk Percolation Test Results Performed { y Date =p �-•---•--•---.. '� minute er i Depth of Test Pit... _ Depth to ground water........................ ,� Test Pit No. 1_.___ '' _ p ............. p fi, Test Pit No. 2................min es pe Depth of Test Pit.................... Depth to ground water........................ a ---•••------- -----------------------------------------•---......----•-------------......---•---......................................................... ODescription of Soil......................................................................................................................................................................... "� - W -----------------------------------------------------------------------------------------•-........------...-----------------------••-------------------------------------------------------••-----•- VNature 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 T ITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the syste in operation until a Certificate of Compliance h b issue y the board of health. r �e 1 ` ............................................... .�. .... -_.... Date Application Approved BY------- -•--•----- .. ..... _ 6 t ............ ..�} ...... /'� "b e Application Disapproved for the f o.owing reasons:--------'--€--- ---------- ---•••--------- ----••------------------ - - •-----------------•-----•---....•-•-------------------------•---•-•-•-••------•-. _...._...............-•--------------------------•-........................•....Date..........--- PermitNo-------------------------------------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF �H ....................OF...:. ........ter ...tF.. :� K3'..... .............. wrrtifiratr ;af ��aaga �t�gaarr IS T T xY .the Individual Sewage Disposal System constructed (r `or�Repaired ( ) by.L -' •`,k' �aa_ ............................................................................ 1' ., e. �nstaller hay been installed in accordance wilY th provisions of TITIF 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__'�6._-__6-3" ..4...... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI ATI ACTORY. DATE.................................. - ....................... Inspector--............•-------•--------•---................-----•--....................... 4 NG ENGINEER MUST IN SUPERVISE THE COMMONWEALTH OF MA%rSY�1� SETjdiji AND CERTIFYIN STRICT tySTA INSTALLED .._ BOAR OF HE ;,'tW WAS Y... ............................................DANCE TO PLAN. No. -- 3� FEE..:>.O........ Dtsp #r -fait Vrrmft Permission is reby granted- . ............................... ------------....-•----------------------..........::..-•---........-•--•••---•..... to Construct for Repair ( ivid e,=age Dis System . -- r Street as shown on the application for Disposal Torks 7ttruction Permit No..................... Dated.......................................... ..................................... - `: -----•-•---------.-.----- oar ofHea DATE---------.••• = 1 c 1 �P FORM 12 5 A. M. SULKIN, INC., BOSTON � CBi(/T r4CIE �- P-7- I I /oT z7 �r zq a BED 'leoQr/14- 47 533t t -- 1 48 f 7 491 c YY L Sgtii� JOHN v CL JACOBI z No.814 UPPERCAPE ENGINEERING w P.O. BOX 616 . E: SANDWICH, MA 025� 362-62 ° ,;, TUP OF FOUNDATIO..N 3 fl.5- R CONCn_TE COVER •�• CONCRETE COVEIcS ..,•'i 4• T 6:4-SOX.r, 'CAS IRON " �./.:^.T n7n ••��� OR SCHEDULE 402 Ak)�. 12"MEiX. 1 ' P.V.C. PIPE _� 4 SCHEDULE 40 P.V.C.(ONLY) . la PITCH I/4"PER.FT _ PIPE- MIN. ' LEACH e.a ?ITCH I/4�PER.FT. PIT. PRECAST °e ENV zT- 10' , a LEACHING E`5`'�` ,,• �INV RT INVERT ' FIT OR •', SEPTIC TANK DIST. 0 EQUIV, .e INVERT EL...XX9 .. BOX EL.. .. . .. : >x ,d. EL:Y.YX��..: . .�e.? .. . GAL. - INVERT .., a .�' 7 ?o INVERT :;�� 3/4"TO 11/," i ELy.X.... cuw .. ELfi... . :.' i.''. WASHED 1 .4 W ..,, STOP PROFI LE OF A10 GROUND WATER TABLE SEWAGE DISPOSAL ., SYSTEM NO SCALE S I L LOG WITNESSED BY : DATE l ,ao ....: TIME ....• •• UPPFRCARE ENGINEERINc,• BOARD OF HEALTH , j TEST HOLE I -'TEST HOLE , ENGINEER ELEVSOX :: . ELEV.. Q:�S. . E: SANDWICH, MA 02537 . . . : 362j6261 . . 0-3 uA DESIGN DATA : NUMBER OF BEDROOMS . TOTAL ESTIMATED FLOW' . �, ,Q , ; , GALLONS/DAY BOTTOM LEACHING AREA ,.�i3 , , , • SO.FT./PIT r SIDE LEACHING AREA . . .�� �. . . SO.FT./.PIT; Ali GARBAGE DISPOSAL . . Alo . ..(50% AREA INCREASE) TOTAL LEACHING AREA , a:G . . . . . SO.FT PERCOLATION RATE ./C�`rss . Z: , MIN/INCH LEACHING AREA PER PERCOLATION PATE .. S1Q.1rT. !�R.WATER ENCOUNTERED NUMBER OF LEACHING PITS .Oyu'. . . . . + APPROVED . , , BOARD OF HEALTH 2; .` �/Y`�•GJ•II �/3 '�` `: J; L/3 /g7�0�J 1 .• n DATE. . . T AGENT-:OR INSPECTOR s ACO Pr . . . 814 n ~ 9�CA'f PETITIONER,**: PETITION • ✓/���Y. .'�OdJ�;, . , . . . � J, ISTf' � �`• •/ �. .Cf / ��? gNAT R\�� BORTOLOTTI CONSTRUCTION, INC. I 13► / _ aF . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO ,, Address Prop "� '��= -A� ansrz� z79 r ------- - - - - 6 5 1995 r Date of Inspec} Map Qo2 Q e7� Own n � co 1 `8 PART A — CHECKLIST .CHECK IF THE•FOLLOWING HAVE BEEN DONE: PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEMAECENTLY OR AS PART OF THIS INSPECTION. AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A: 4—THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE, DEPTH OF SCUM. f/ THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY.NON-INTRUSIVE METHODS. v THE FACILITYOWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER F__MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL No of Bedrooms —No of Current Residents Garbage Grinder Laundry Connected to System /l� Seasonal Use NON RESIDENTIAL: Calculated flow ` WATER METER READINGS,IF AVAILABLE: GALLONS Pumping Records„and.•Source of Information: SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED= GALS Reason for Pumping - TYPE OF`SY.ST._EM �=Septic`tank/distribution box/soil absorption system :Single C.esspool': Overflow Cesspool Privy "=Sha d,s stem F(H, es, ,attach previous inspection records, if any) Other- ,,,plaiinj Approxl mate age mof'A11 comppqpponer>ts. .; Date Install JJed,if known. Source of Information. 41 'SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? /Y 1• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART B — SYSTEM INFORMATION (Continued) SEPTIC ANK: Depth below grade: Dimensions: S/ i Material of construction:. Concrete Metai FRP Other} Sludge Depth Distance from top of sludge to bottom of outlet tee or baffle 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 Comments: I 6 a Gl�. Cos 01 S G�i' g `1 40 s/ d DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: •d_ Gc�4�/�� /eve . eL �y p — IV �PUMP _HAMBER: Pum s in working order? Comments: SOIL-ABSORPTION SY TEM SAS IF NOT PRESENT,EXPLAIN: TYPE: /11-Ccr/ Ze Cdch Comments: cx)Lj / s /ram T CESSPOOLS;' v Number and configuration Depth—top of liquid to Inlet Invert Depth of solids layer Depth of scum layer Dimension of'cesspool Materials of construction indication,of groundwater Inflow(cesspool must be pumped) Comments:': PRIVY: - d' Materials of construction Dimensions,--' Depth of solids Comments f °V r -'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r., PART B —SYSTEM INFORMATION (Continued) SKETCKOFrSEWAGE-DISPOSAL SYSTEM: INCLUDE TIES TO.AT'LEASTTWO PERMANENT REFERENCES,LANDMARKS OR BE NCHMARKS. LOCATE ALL!4 L1 WITHIN.100' v O ij f r4 DEPTHTCQI3WATFIa. DEPTH TO GROUNDWATER � MEiH00`OFlaQ TIONORA�P,ROXIMATION:. r t Anal. Ic)e y� s �r�J{ti+k �f •. rdx��3;��.,.t�i4�.s�i�'+ - 1j� �r�`a a� {5:,`. i ..... ,1 ;t t W 11 rr$ rF t 4- z 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA QndkaEs Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.) / Backup.otsewage into Facility? /lr Discharge or ponding of effluent to the surface of the ground or surface waters? `Staticnligwd level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? ✓l� :`Requited pumping 4 times or more in the last year? Number of times pumped t a Al 'Septic;tank.is metal?cracked?structurally unsound?substantial infiltration?substantial exfikration? tank,Jailure'imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50'feet of a surface water? ,.Within-1.00.feet of a surface water supply or tributary to a surface water supply? Wthiti,a'Zone I of a public well? Within:0 feet of a private water supply well? Within-..50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? .Less than':1004eet but greater than 50 feet from a private water supply well with no acceptable water ,qualityanalysis?`If the well has been analyzed to be acceptable, attach copy of well water_analysis for colif '!'4,acteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS NY COMPA - ABORTOLOTT[.C.ONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATIQN STATEMENT e'4 � I CERTIFY-- �iAT I`Hff'EFPERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND•THAT THE INFORMATION flEPORTEDa6J TRUE`'ACbURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS.PERFORMED AND ANY RECOMMENDA' IONxREGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN:THE PROPER,100,1ON'AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK.ONE. 4„ r ;[,HAVE NOT,FOU.ND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC 1EALTH�QR;THEiENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED:ARE AS {' STATr ?LN�TFIE�"FAILURE CRITERIM-SECTION OF THIS FORM. I HAVEDETERMINED THAT'THE SYSTEM FAILS.TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CAA 303,'P HE BASIS FOR THIS.DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS 'FORM ,f .� s INSPECTOR'S SIGNATURE ' , IV r DATE ORIGINAL+TO SYSTEM QWNER COPIES BUYER if' :, Y ,yRA - 7 ' . r ( applicable),APPROVING AUTHORITY a +t S x C r as is No. - ---- --- -' Fee- ------- BOARD OF HEALTH TOWN OF BARNSTABLE Application ArVe[Y Congtruction3oerntit A lication is hereby made for permit to Construct ( ), Alter ( ), or Re air ( )an individual Well at: PP Y P P y- Lnit ocafdn - Address SyS]Y>Ssesso� - -n``'s Map and f ----- �" EC -�1 - — r �l I U�-'►_I I — �5�` c�- ------------ Installer Driller Address Type of Building !SC"1C1Wt CJA JA ®aSCo3 Dwelling------ -------------------------------------- Other - Type of Building---------------------------- No. of Persons---------------------- �� --- ------_-- Type of Well— — 9�,� C- ='v.Qa'1�-- Capacity------------------—— --- Purpose of Well---- 1 nl�•—n -------- — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certifica f qompliance has been issued by the Board of Health.Z'6 KO p Signe date Application Approved By -- " — --- date Application Disapproved for the following reasons: ------------ — -- ---------------------------------------- ---- date Permit No. -—--- Issued----- - - ---— ---- — ------ date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Comphance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repairedby ( ) (► �-��a� Installer at— cr1j,has been installed in accordance with the provisions of the Town of Barnstable Boa d of H mlt Private Well Protection Regulation as described in the application for Well Construction Permit No ated----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------- -- —- Inspector—_ ------ - --- — —_ .. .-.,�,. . •�u..a;,y..^oi..,.a,-•r.. k*•-rve.•t• rAq-" -.Nr�.4 W+W+ .v.,, ,_..-„ -.:,.•i-i. � . "' . No.' - ---- -== ----= -Fee---�-5�-- -------- BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rlVell`Con5truct ion Permit Application is hereby, made-for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: �-� _M 6(x s;IIn -- -Loca w .•a-tAddress ` -_q - Assessors Map and;Parcel . __ �a 1'1-�---- ---��=-�=-�-��-�--=----- ----=-- ------Vic`-r"�-_-;- -------- ----- ------- ------ Owner Address -�_,� f 2�lA�r1---°- -_- .---- -��' - , 13C� =l� ' —�----------- '.Installer,- Driller - - - Address 1 Type of Building Ci't © S(43 Dwelling - � - -------- - Other - Type of Building; — ---- ------------ No. of Persons------------------- ----— ---- Type of Well'-- �- —R=�`'--A1c,C f - Capacity=-- ------------- Purpose ----—- -- ——— of Well Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of.Barnstable Board of Health Private Well.Protection Regulation The undersigned further agrees not to place the well in operation until a Certificate f: hornpliance has been issued by the Board of Health. Q Signed --- e —date Application Approved By --- -© - --- - � date i Application Disapproved for the following reasons: ----=----=------=--------------------_—_�____—_ — --- — Y date 4 Permit No. — — Issued--- - - -=--- ---='-f - j date !i,�.ia4:satiesecla�oau+yaiii.:,in:,aae'4le.l�K:xw lte•�uE•GPc'OiSiRsaaa�lebr6am+Ionasewaic�i3oes�esararerETaaEs'aaesa4see++:Gei,ea+ra+lNlf ToA�?SA•sacaa.lciiYassoeuraavd:seat:.e-.etP`:!!s.b��'}.'e:'° BOARD OF HEALTH TOWN OF BARNSTABLE e t"f irate ® Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (. ), Altered ( ), or Repaired ( ) (t7�Rlt-P14 c� by ���Installer���—��D In �-- � i-�`—'—----has been installed in accordance with the provisions of the Town.of Barnstable Bo r, of Healt Private Well Protection i Regulation as described in the application for Well Construction Permit No.1/ -Dated----,r THE ISSUANCE OF THIS CERTIFICATE SHALL!NOT BE CONSTRUED AS'A GUARANTEE THAT THE WELL 1 SYSTEM WILL FUNCTION SATISFACTORY. DATE---- -- Inspector—�- —- �Ye.+lilaFa�:et�:#6tat�!arae4.eat.93•tce4sie3t;eaaL9a�:saewea9►arsay.ew:eua3•aeAeaeaereasaTs!!YtwtrWfalataeaectae4ecpeeaaala'/Ma.YtoTe�a'�ee.+N�.?r..a�a�::tirSL�at.+:T�+Gr.,sa!+ava... BOARD OF HEALTH TOWN - OF BARNSTABLE . Veli Conotruct ion Permit No. ------ -- Fee— Permission i he eby ranted gg �! `a< Q to,Construct ( �), Alter ), or Repair ( ) an Individual.Well at: w No. —_�_ +� G� -tsa4 J c' C_ -—=-1�'� -!'Sto,1 �i` I J-�=s MA '- street as shown on t e p 'cation f Well Construction Permit No.- ----- Dated -- -- --- - I Board of H alth j DATES