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HomeMy WebLinkAbout0624 FLINT STREET - Health 624 FLINT MARSTONS MILLS J YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town(which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form 'at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. E attu DATE: � 2�1 I� Fill in please: APPLICANT'S YOUR NAME/S: 1-1/tA60MIR ASENOV NYAGULoy w z�r,b "t. U: BUSINESS YOUR HOME ADDRESS: �Q1{ !-L NT S T , l` AP-ST OIVS IU I/-L hdA 9-(o1-t g Z7ti aq11 231k1 > l2 TELEPHONE # Home Telephone Number NAME pF CORPORATION; L:.,�. AI IJ s ca.a►IJ G NAME OF NEW BUSINESS TYPEIV d SGD/N Cr OF gU51NE5S Lg IS THIS A HOME OCCLII?A ION? YE IVO ACIDRSS OIF BUSII� SS� H Rs l O 5°'. . tL1.S MAP`PARCEL NUMBER US.Ll. A t;, ['i. When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - [corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has een ormed of the permit requirements that pertain to this type of business. �,(-y ((/� r'ViUS7,;,Wl'LY'vUITy ALL p.in�,x� !141 C Authorized Signature*"` R'7('I!I TI, - - COMMENTS: 3. CONSUMER AFFAIRS[LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: f ,+ Date: �/Z 1/ �f TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: L .A .1V. D scap pm , BUSINESS LOCATION: INVENTORY MAILING ADDRESS: GA4 )dru P-L I IUT � . : ���9 Oil I� I LLB 12f�¢IgTOTAL AMOUNT- TELEPHONE NUMBER: 7-M 9 9� 231� CONTACT PERSON: 1_,1P LA p60m I R All-A&Y-0Y EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: Lave Sca "vt , INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes LA �-c Jt � Q D_L, Laundry soil &stain removers (including bleach) Ott ho� S�O Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS A n ' re Staff's Initial COMMONWEALTH OF MASSACHUSETTS a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS v d DEPARTMENT OF ENVIRONMENTAL PROTECTION A� `� �•��� Ricky L.Wright- Certified Title V Inspector,508-477-0653 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 624 Flint Street Marstons Mills, MA Owner's: Frank&Tara Merolla Owner's Address: 624 Flint Street Marstons Mills, MA 02648 Date of Inspection: March 13,2009 i p Name of Inspector: Ricky Wright -License#.S14595 �,.. Company Name: B& B Excavation, Inc. Mailing Address: 14 Teaberry Lane Forestdale, MA 02644CD Telephone Number: 508-477-0653 L' CERTIFICATION STATEMENT , I certify that I have personally inspected the sewage disposal system at this address and that the info tion reputed �E- below is true,accurate and complete as of the time of the inspection.The inspection was performed b ed on myn training and experience in the proper function and maintenance of on site sewage disposal systems.I a a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails 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 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: The information as identified represents only the condition of the system on March 13,2009 at 1:00 PM. ****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 Y. -- conditions of use. ` r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 624 Flint Street, Marstons Mills, MA 02648 Owner's: Frank&Tara Merolla Date of Inspection: March 13,2009 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 (THIS IS REQUIRED TO BE COMPLETED) 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: Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 624 Flint Street, Marstons Mills, MA 02648 Owner's: Frank&Tara Merolla Date of Inspection: March 13,2009 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 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 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:The primary cesspool is not a typical configuration for a cesspool. It appears to be a pipe cylinder with an inlet pipe and outlet pipe with tee connected to a pre-cast 4'deepx6'diameter leach pit with stone. Permit on file with the BOH for the pre-cast leach pit. OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r Page 4 of 11 PART A CERTIFICATION(continued) Property Address: 624 Flint Street, Marstons Mills, MA 02648 Owner's: Frank&Tara Merolla Date of Inspection: March 13,2009 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow _ X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. X_ 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.] NO (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 U 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 624 Flint Street, Marstons Mills, MA 02648 Owner's: Frank&Tara Merolla Date of Inspection: March 13, 2009 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X_ Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X_ Have large volumes of water been introduced to the system recently or as part of this inspection? X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X_ _ Was the facility or dwelling inspected for signs of sewage back up? X_ _ Was the site inspected for signs of break out? X_ _ Were all system components,excluding the SAS,located on site. _X _ 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? _X_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No X _ Existing information.For example,a plan at the Board of Health. X_ 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)] 11FFTf T A T.TNCPF.f TT(1N Ff1RM_N()T FnR V()T.TTNT A R V A CCF.CCMF.NTC Page 6ofII PART C SYSTEM INFORMATION Property Address: 624 Flint Street, Marstons Mills, MA 02648 Owner's: Frank&Tara Merolla Date of Inspection: March 13,2009 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 3 of bedrooms): 330 Number of current residents:_4 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):N/A Seasonal use:(yes or no):NO Water meter readings,if available. Sump pump(yes or no):NO Last date of occupancy: presently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Yarmouth Health Dept Was system pumped as part of the inspection(yes or no): no If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X 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) _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(deseribe): Approximate age of all components,date installed(if known)and source of information:Approx.9/24/98 Were sewage odors detected when arriving at the site(yes or no): NO t /1TT71r!�7♦T TATO'nW"rVlrf%�T TAT ILK IkT/%T TA / T T %71T TTICT ♦"I&T ♦C1V1rC1C11LK1r ICTTC1 'n r Page 7 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 624 Flint Street, Marstons Mills, MA 02648 Owner's: Frank&Tara Merolla Date of Inspection: March 13,2009 BUILDING SEWER(locate on site plan) Depth below grade:Approximate;3 feet Materials of construction:_cast iron X_40 PVC_other(explain): Distance from private water supply well or suction line:_greater than 100' Comments(on condition of joints,venting,evidence of leakage,etc.): At time of inspection,pipes,joints&venting appeared to be in good shape SEPTIC TANK:N.A.(locate on site plan) Depth below grade:2%1 Material of construction:—X—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: 5.5'H X 10%X 5.5'W Sludge depth: 6 inches Distance from-top of sludge to bottom of outlet tee or baffle: 4' Scum thickness: none Distance from top of scum to top of outlet tee or baffle: no scum Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) at time of inspection;tank,tees and baffles were all in good working order GREASE TRAP: N.A. 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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 8 of 11 SYSTEM INFORMATION(continued) Property Address: 624 Flint Street,Marstons Mills, MIA 02648 Owner's: Frank&Tara Merolla Date of Inspection: March 13,2009 TIGHT or HOLDING TANK: N.A._(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:_yes_(if present must be opened) Depth of liquid level even with outlet invert:liquid level is above the outlet invert. 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.):at time of inspection,d-box is structurally sound and water levels were equal to inverts PUMP CHAMBER:,(locate on site plan)NA 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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f Page 9 of 11 SYSTEM INFORMATION(continued) Property Address: 624 Flint Street, Marstons Mills, MA 02648 Owner's: Frank&Tara Merolla Date of Inspection: March 13,2009 SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number leaching chambers,number:3 infiltrator maximizers _leaching galleries,number: _leaching trenches,number,length: leaching fields,number,dimensions_ _overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc j No ponding on ground. No excessive growth of vegetation. Did not expose leach pit due to conditions found in distribution box. 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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Page 10 of 11 Property Address: 624 Flint Street, Marstons Mills, MA 02648 Owner's: Frank&Tara Merolla Date of Inspection: March 13, 2009 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. A 1 Lj A1 =32' B1=26' A2=44.6' B2=41' A3=51' B3=41' 1 z-� Septic Tank Distribution Box Leach Pit l Page 11 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 624 Flint Street,Marstons Mills, MA 02648 Owner's: Frank&Tara Merolla Date of Inspection: March 13,2009 SITE EXAM Slope 1 % Surface water none Check cellar (crawl space)yes Shallow wells no Estimated depth to ground water greater than 15' Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:Recent Test Holes, Existing engineer records with BOH Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: F0RM30 C,W' HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /4 fZ l0 t CITY/TOWN b0�Dt b DEPARTMENT q, ?6 7 7 ADDRESS (/� ®y /Jam(/ W/ G„M Sey\0 V V d / V / TELEPHONE Address G 2 LI F11"t 1 t, '00+�f"k-/,4t /i Occupant u t--14,d _ Floor Apartment No. No.of Occupants No.of Habitable Rooms 3 No.Sleeping Rooms No.dwelling or rooming units -/No.Stories Name and address of owner F,4 � 1_- 01 ev0 It, 2 Fl t A,1 Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish O.-­AXS Containers: 4y Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: p Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Ci*e ,.w - Ir C C­-ee-"S-0t< fA,wtdtvv-o Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: zia Dam ness: A/V Stairs: .vim - Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceilin : 4 3SJ Hall Lighting: (A Hall Windows: HEATING &VV3 Chimneys: Central H'-Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: wig - L)4il,4 4 ❑ 110 ❑ 220 Fusin ,Grnd.: V! �a AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT P ikVVQ Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks P4943 Kitchen Li cIr Bathroom IT tZ Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Su .Ten. a , Oil, Elect.: 1,30 OE Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove C-A L- P fir m -mot//Q c,✓ Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: -CJL ok Wash Basin, Shower or Tub: 1/ G� DGL Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: 0`1 y i c>l v 4v 4w-4,- Sflso General Building Posted ('`w- Locks on Doors: eK ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALT=, PTw;iff INSPECTOR TITLE /4c�tif A.M. DATE /t/"7 TIME �� A.M. THE NEXT SCHEDULED REINSPECTION P.M. :.:xr'•:•r •.at•.r �, ;..,., .,P;,�,,... .......:t.;.s�,.^...K .., �ry.. . .. ., m..,1., ,. ,w',':ijl�rNln�,iS ;+t C,U:7y=t' +d. '•` `�M«TiAcp,` :^G,•..�t,Le...z ,y ....t„�, _ ..-. •.v«} 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing'is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whomtthe order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G). Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers"or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in'accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock', accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pu verized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in'105 CMR 410.7 50(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. I k+" FORM30 Caw HOBBS&WARREN'M fTHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN w A'A / 4 a DEPARTMENT ``��� ADDRESS yd N TELEPHONE Address __�_. _ —_ - . .____Occupant_- __ _ Floor Apartment No. No.of Occupants—/ No. of Habitable Rooms__—No.Sleeping Rooms_— No. dwelling or rooming units__ No.Stories Name and address of owner 7F►'&_AA 1 _01 e_v01A _�___6 z Y F1i"t S 7I `V /L'+ Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish 0tA-wX3 3 �rl di G� G�ryi,,1 Tau J to Containers: 4u 1k4- S+ Y OW ou,-, Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: 0 Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: CG)?V•W+ Lj C cv-eev►S-Ou t4,w &-vv-OGC Roof , Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen. Sanitation: G.'riu d Dam ness: AIV i Stairs: I& - ,Q�vt 4o r+~ oU Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceilin : CWcL4 ,. S $ ►y o'I Hall Lighting: LA ' -r_ly,,, — 2 -C.00 f N Hall Windows: HEATING 6-A- Chimneys: Central S?"Y ❑ N Equip. Repair TYPE: lc#k/ Stacks, Flues,Vents: a PLUMBING: Supply Line: 1n i�-a ❑ MS ❑ ST ❑ P Waste Line: S— H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: / Wi 4,e-,, - V4!fi ��4 ❑ 110 ❑ 220 Fusin ,Grnd.: C r AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT S4t vVQ Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks (3e-{5 Kitchen Lfvr Bathroom 8 t2 - Pantr Den Living Room Bedroom(1) Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,O, Oil, Elect.: / o OF Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink j 6 Stove CA Y tr L-/ Bathing,Toilet Facil. Vent., Plumb.,San it'n.: 41,& -c -C_to)L--,1 O(C Wash Basin,Shower or Tub: V + j r ti f OGc Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: O'^ 1 qow 4v 4fw4, &,v4k General Buildin Posted \ Locks on Doors: G)G< ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES�O�/�,' P R JU, INSPECTOR TITLE may, A.Mom. DATE �.dT1y TIME �� v`� _ � P.v4. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.6.20 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for.Lead Poisoning Prevention and Control, 105 CMR 460.000. .(See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock,accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. G ; TOWN OF BARNSTABLE ✓ LOCATION �,l' ���iT ST SEWAGE# VILLAGE !d/.Z44%/S ASSESSOR'S MAP & LOT 22 dfd INSTALLER'S NAME&PHONE NO. 4 77 03 EV /W rVZ, SEPTIC TANK CAPACITY /Sao LEACHING FACILITY: (type) 3 47 40xi61-116_,"15 (size) NO'.OF BEDROOMS BUILDER OR OWNER 14 e -� PERMTTDATE: R COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist , on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility), Feet Furnished by ��r vt� �f ,,, �� `-�' � � � � � �I � a `�, � �• r c� �i/ate/�� �J� �c> � o �� � �� �. � nn THE COMMONWEALTH OF MASSACHUSETTS FORM30 <1 IhW> HOBBSBWARREN' BOARD OF HEALTH /L1 fZ V. Jill'/ DITY//,T,O- �- WN f W _/7e,/ , lll 0 DEPARTMENT o ADDRESS TELEPHONE G 2 y JF11n f f F- '0f ,)k-u�/� 11/4 D�ti /, Address � ___ Occu ant_. 'I'r/ P Floor .Apartment No.___-.___._No.of Occupants_--L No.of Habitable Rooms_-3 ___No.Sleeping Rooms_ f No.dwelling or rooming units J_ No.Stories_______ Name and address of owner &&.g OJ Cv__y lot_ _ Z 1„�-� S�f ., 44 Al Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish 3 a,,.,#x3 3 ►-vv;dr 61 4V4,,,1 fl., Containers: 0W Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs,Porches: 0 Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Crae yAm 4- Ir �v �e�S-0� S'4,an C6.,-v Roof Gutters, Drains: Walls: Foundation: Chimney: I BASEMENT Gen.Sanitation: va Dampness: x/V Stairs: ,&-v - Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: ,6 el 0Q144#-% ` S—/ Hall Lighting: - 2 1 Hall Windows: HEATING Chimneys: Central 1TY ❑ N Equip. Repair TYPE: G.✓ Stacks, Flues,Vents: PLUMBING: Supply Line: '/-rL.• "44— OMS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: Z mX, - V4t , 7� -e ❑ 110 ❑ 220 Fusing,Grnd.: ti AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT S,4tcrtxf Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks p2cf) Kitchen Lt v r Bathroom IT t2 Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten. a ,Oil, Elect.: / 0 v Stacks,Flues,Vents,Safeties: Kitchen Facilities Sink Stove 6�4 (-I D Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: -6 iv,-� -6-r-15 @ ©k Wash Basin,Shower or Tub: ; &* ok Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: 0"1 I -v- 1v l4L„Y,� General Building Posted - 1 Locks on Doors: �J ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIEW P RTT�Lv INSPECTOR TITLE —,44,A DATE A.M. �I �UU TIME �� A.M. THE NEXT SCHEDULED REINSPECTION P.M. No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: •� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Miopoml *p.5tem Couttruction Permit Application for a Permit to Construct(pair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 6 211 57- Owner's Name,Address and Tel.No. �i�Nsro�s :v dl- Jw"_-5 4004-eY Assessor'sMaplPazcel 0!2, OSV � 2 li l !O rrS Installer's Name,Address,and Tel.No. o: S/q Designer's Name,Address and Tel.No. al d lgnees l /4-1 %/• 510" 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 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 's�dlrAt/ Nature of Repairs or Alterations(Answer when applicable) /!' Lr' � T xg l,4/1 3 rYtsatX ll�ri�t^� cu>r� �l` Sro�i f4.Hrac/�. 2 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 Board of ealth. SignedQ. Date 9- / Application Approved by Date /7- Application Disapproved for the following reasons Permit No. Date Issued cP—/7- No. H Fee IS-0' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN',OF BARNSTABLE., MASSACHUSETTS Zlpplication for Diq gar *pgtem Congtruction Permit Application for a Permit to Construct(pair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4,21/ 5 r- Owner's Name,Address and Tel.No. Assessor's Map/Pazcel O v s O 2 XiNT 5r Installer's Name,Address and Tel No. 4/1 7 3 y O ? Designer's Name,Address and Tel.No. ✓osepd, 1), (�Arr+,'S / sx 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 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 - �f rp�y�/u Nature of Repairsi or'Alterations(Answer when applicable) Aill J_`_X1SrjW (' ae S gar, o3 fa// 3 sst�x i i',,i�rs w�rG, y'Sron /4rl ya 2 " 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 Board of ealt . Signed „a Date - '7' `/-F Application Approved by Date - 17- Application Disapproved for the following reasons Permit No. 33 ;Date Issued 1-7 9 ��r; THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( daired( )Upgraded( ) Abandoned( )by jo e-,04 &e (3asr.�o at 61 y _af -' Sr itajorSro hs, 41,71s has been constru ted in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 59 E s23 dated f`/7` S Installer Designer The issuance of this mit�sl l n construed as a guarantee that the syste ild. unction as designed. Date JJ,, j 11 Inspector No. �G "'S-3� ---------------=-------=---Fee THE COMMONWEALTH OF MASSACHUSETTS �b2 6 Sj PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'Wigpogar *pgtem Congtruction Permit Permission is hereby granted to Construct( G.-'Repair( )Upgrade( )Abandon( ) System located at ti 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 it. Date: w 7 '/ Approved by TOWN OF BARNSTABLE LOCATION _ ,G��,T" ST SEWAGE # VII-LAGE_�Y/, ASSESSOR'S MAP & LOT12 9, INSTALLER'S NAME&PHONE NO. 4 77 43 qg ram/ SEPTIC TANK CAPACITY l r e o LEACHING FACILITY: (type)=� �' six i syi �=�s (size) NO.OF BEDROOMS BUILDER OR OWNER JAI PERMTTDATE: COMP, I.I/ANCE 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) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of,leaching faciyl� Furnished by I��,Q,� Feet h �r t � s� c 0 S 1 a Ei tOJ9N1 NOTICE: This Form Is To Be Used For the Repair Of Failed Slsptic Systems Only, CERTI)FJ1CATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works consttvction peimnit signed by me dated_ � 98 .concerning the property located,ti-t meets all of the following cdIMS,:: ere are no wetlands located within 100 feet of the proposed leaching ftellity "ere are no pri ite wells within 150 feet of the proposed septic system no incmeme in now and/or change in use proposed 'I s"aro-no vatlances requested or needed. �Iheprnoposed(+-aching facility will be located within 250 feet of any wetlands,the bottom of the proposed leechinl;Ncility will not be located less than fourteen(14)feet above the maximum adjusted groundwater tables elevation. Please complete 111he following: A)Top ;,f around Elevation(according to the Engineering Division 0.1.9.map) !Z B)Obsuved Groundwater Table Elevation(according to Health Division well map)q_ 910NED 4011. 1.o� / '".= DATE:/7 LICENSED /SIEP 17.1C SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER Y y tAllach a sketch plwi of the proposed system,Also If die licensed installer posesses a certified plot plan, this plan should be-submitted). q:We*Maw:ad 1%���r- .�� . r`'x�9r�h9 io 0o G�1. �, Xis rrtiq �aao G� 1, Sr a THsr��/ 3 rh,�x,�,�=rs cc/rr� y'�for-� 4�' v�ii� -�ro�l� �aruv,cf -� l•.00L.TION ' 5E\NaC4E PERMIT UO. lAlS LL+ R5 IJQt�E � ADDRESS e BUILD R 5 1.1l,I.AE ADDRESS �VD47E PERMIT ISSUED �qD ATE COMPLI &&ICE ISSUED ; � ,�� � ... ���! ,-... t .��� .~ �E el �� � a�i• `�.��� v THE COMMONWEALTH OF MASSACHUSETTS .BOAR® OF HEALTH 7'7��-_.�N. ..OF..... f?./ n7- ............................ .fie liration' for Big niittl Works Tomitrurtiurt Vantit Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal System at: L_ T z 3�2�- �/ , , ................_..--- ..............._..... ...... ............................... ........... - .- Location-Address or Lot No. .............�17.st 't✓! / lZ _ ram_._......1.`?--Ke-e...... Owner Address W Installer Address 2 J s� UTvpe of Building Size Lotr{__....I-------•-------...Sq. feet Dwelling—No. of Bedrooms.................-3....................Expansion Attic.4--j-- Garbage Grinder '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ............................ . W Design Flow.......................F^ ---------------gallons per person pqr day. Total daily flow...........0- 9._............ all ns. WSeptic Tank—Liquid capacity.k gallons Length___-_� Width__`�._f®_ Diameter_______________ Depth...'_ ........ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------J---------- D ameter___f __.___.._. Depth below inlet__-��__. Total leaching area._E.`� .....sq. ft. Z Other Distribution box ( 1 Dosing tkr f Percolation Test Results Performed by................1._._..._._...�z���J.__....:.==f�c Date..__�_..����_ ,.a Test Pit No. 1. —2--minutes per inch Depth of Test Pit---,/.........._.. Depth to ground water...... � ... _- f=, Test Pit No. 2_._=..Znunutesper inch Depth of Test Pit Depth to ground water------- -3-at... a ..................... 0 Description of Soil----------- coca r'� 2 -�-I �' �'..............................................----------------------------------------------------- . x W Nature of Repairs or Alterations—Answer when applicable licable--_____ 1.�.1 / ............ 1..................:................... U P � .��- Agr eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I- p 5 of the State Sanitary Code— The undersigned furtl er agrees not to place the system in operation until a Certificate of Compliance has been is Wed by he board of health. Signed-�..................... .................•------------•-------... Date Application Approved By. J.� ----. =----------•- -------f.-I........`--', fZ------ Date Application Disapproved for the following reasons---------------•-------------------------------------------------............................................... •-------------------••----------------•-----•---------------•------------•-------•------•--•--•------------...-•••-----•-----•---•--•---•-••--•--•--•--------------------•-•-•-••---------•--•--•------ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS -�-' BOARD OF HEALTH ----..1.... ....!✓/✓.....OF..... 2 NS.T`�3.,r3.. ................... Apliftra#ion for DhipmiFaf Works C on ra�r ion ermi Application is hereby made for a Permit to Construct (r ) or Repair ( ) an Individual Sewage Disposal ' System at: _ �' .............. _ -.._.............. .............. ............................ _.'�.•-e:e..�_ ......... .... ` % ✓Loc r s or Lot No. ! .�"M 1E'/ t�. �T?- I ,l-', l� , rV '2 .t� ._©. ►�/ y Move-�i -- ............... ........ ..... ---.............._..�._._.. 7'......_....... r 1 .................. ,.,r Owner Address W Installer Address Type of Building Size Lot...2•.1--'` 'Z..0....Sq. feet Dwelling—No. of Bedrooms.................•. ....................Expansion Attic...(•-Ir Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QIOther fixtures .........................-....................................................--------------------------------------------------.-•------•------------ Design Flow....................' ........_.__gallons per person er day. Total daily flow____..__.. -3 0_.._._........_..gallons. WSeptic Tank—Liquid capacity. gallons Length___. .r_ Width..i-..___ .. Diameter................ Depth... ......... x Disposal Trench—No. .................... Width..................... Total Length.................... Total leaching area....................Sq. ft. � pSeepage Pit No.--_-___.�.--.---_-- iameter-_ _-___-_-_- Depth below inlet..-vim ...... Total leaching area_!..`1.._._......sq. ft. Other Distribution box ( i� Dosing0-4 t a ` , 1 1 1�C / Percolation Test Results Performed by....... .................................. ....: .�--...--I�`---.-= Date.... r . ,aa Test Pit No. 1 G--'•minutes per inch Depth of Test Pit___�J../........ Depth to ground water.....�-�._.t (i, Test Pit No. 2..'C_'....z.niinutes per inch Depth of Test Pit__.1-.......... Depth to ground water_.-__-J-3............ ........................................... , --.......... C. f O Description of Soil.......... `mac ..r'�..do_ ...,��l •-..-. } /�� ................................................. x . ........................................................••-------•-•-----------------•----•-------------------.......---------------- 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 f'l T/'1 ., 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has yybeen i sued by the b and of health. ga-----------• r Date Application Approved By::�1 '...... Ie'`�:�'...........................•-- , Z'-;/�------ Date Application Disapproved for the following reasons:................................................................................................................ •-•••-••---••--••-•••--•----...•----•••-•-•••••••---••••---•......•----••••---------•---•----•-•--••---••••••-•••-----•--•--••-•-------------------•-------•••---••--•••-•--••••-------••---•-••-••-•-•- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ....... ..........O F.....-B 0.. -. :W--5.�. 04:6--a 4.—jEF Trrtifiratr of TontpfiFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (1.-<or Repaired ( ) by-•....••--•-•-----•...................................••-•••-•-...................••-••-------••------•••-•-•--------•-----•-----•--------------•--...-•---------...---------••-......----.._..... Installer at C e-e � r .............................................. has been installed in accordance with the provisions of TI; E'' j of he State Sanitary Code as described in the application for Disposal Works Construction Permit.. _ ............. dated----------------------------------`-•---•••••• si THE ISSII NC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE SYSTEM WIL F CTION SATISFACTORY. DATE........ --•�- ----------------------•-•--•---•--•--•---------- Inspector----•- --- ------------ ...................................................... y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH e9/ 8 O �.!�.......O F......... ����1/S. .t?..v.�—�-'... ........ .... FEE—Ti.............. Diopoottf VorkgSono ratr ion �erutt PermissioP��or ereby granted------------------------------------------------•------------------------------------•----•----------......--•-•---------.................... to Construct � epair ( an In ividua Sewage Disposal Sys at No.._./-chi... .3/ / CJ ---------•-------------------------•--�-------�. -•-------------. ........d�r Street as shown on the application for Disposal Works Constructio rmit No.....................S)ated.......................................... DATE...f- ? --t -- / _3------------------------ ------------- ---•--•--. ^65rd of Healthy FORM 1255 HOBBS & WARREN. INC.. 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