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HomeMy WebLinkAbout1351 OLD POST ROAD (CT & MM) - Health 1351 OLD POSTJIARSTON MILLS 057 029 Rill r" r• i �i r / Town of Bar)[I stabk _ iKE Department of Regulatory Services Date Public Health Divisioll �l t" 200 Main Street,Hyanuis MA 02601 days Date Scheduled Time f U. Fee Pd. trWlJ�_1' `oil Suitability Assessnient1for >. enpag- �isposall PcrYanned By: Witnessed By: ! �` ILOCATIO & G>CN ERA L I[1V><ORIVIIA7I'ION Location Address '— Owner's Name M M 1 6 U Address n Assessor's Map/Parcel: J Engineer's Name NEW CONSTRUCTION IrRBPA1R Telephone ff CS U4 Land Use P Slopes(%) Surface Stones Distance's From: Open Water Body ft Possible Wet_Areay ft Drinking Water Well ft Drainage Way ft Property Line ft Other _ ft SKETCH., (Street came,dimensions of lot,exact locations of test holes&perc tests,locate wetlauds'ln proxinity to holes) 3 C) C7 jV l Q` , C� 09 Parent material(geologic) `r+� Depth tq B3 drools 90 , _ Depth to Croundwaiei': atanding fYaier iii dole: -wcepiiig(I?i17,Pit Roc Estimated Seasonal High Gioundwater • i D E'I<'ERAUNATI ON FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.!lute: In, Depth to Soil inluUl..gs: In, Depth to weeping from side of obs.hole: In. Groundwater Adauslment•,e,� -fr. Index Well I# Reading Date: Index Well leYnl _ v� Adtl,Awtor— A41.0r0L1l7tiwater U"l Observation I`ERCOLA x I.O x ES Datu Aluia 4_ Holc#f i1 Time at 9" Depth of Perc red Time at 6" Start Pre-soak Time @ Time(9"-G') End Pre-soak Rate Min./Inch f Sitc Sujtabillty Assessment: Site Passed SiIG,Failed: Additional Tesling Needed(Y/1\1) Original; Public Health Division Observation Hole Data To Be Completed on Back------ ***If percolation testis to be conducted vviLiiin 100' of wetland, you mush first notify Hie. Barnstable Consel'vlidoii]Division at least one (1) week prior to begflnidug. QAS EPTICTERCPORM.DOC DEEP -OBSERVATION HOLE LOG Dcplh front Soil Horizon Hole#• Surf,�ce(in.) Soil Tex(ure Soil Color ' (USDA). Soli' Other (Mansell) Mottling , (Structure,Stones;Boulders, Con isle c %a ravel f oe DEEP 0'?SRRVATIONI-TOLV LOG Depth Pram Soil Ho Hole # Z Surface(in.) Soil Texture Soil Color (USDA) Soil Other (Mansell) Mottling (Structure,Stones, Boulders. i Cons! enc %Gravel DER P ®BS]El[�VATI®N HOLE Depth from Soil horizon I®� Hole# Surface(in.} Soil Texture Soil Color (USDA) Soil Other (Muns411) Mottling (Structure,Stones,Boulders. ('•o_ rS'stencY %Gnvelt .... i wrvw'4 ti-w — -------------- ------------- DE]EP OBSIE RVATION HOLE, LOG M Depth fi•om Soil H Hole Horizon Soil Texture Soil Color Soil #— Surface(in.) (USDA) ,• Other (Mansell) Molting (Structure,Stones;Boulders, Cans tency eG Oravel) ,t Mood lhslfr6ci Rate Ida p. Above 500 year flood boundary No Yes Within 500 year boundary No 1 Yes, Within 100 year nooti boundary Noye5 Depth ot'Naturally Occurring 1E ea'Vious Materfal Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? e If not, what is the depth of naturally occurring pervious mato►'ial7 Cetr aflcatcation 1 certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analy.-is was performed by me consistent with the required training, expert' e and experience described in CIO CMR 15.017, Signature Date y Q:SSEPTICIPERCFORM.DOC y I r TOWN OF BARNSTABLE BOARD OF HEALTH r(� ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date l " Time: In /0 00 Out 16 -,)5 Owner r Tenant Address t C_( Cn Address Complian,e Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities _ - Approved: 3-- 4. Water Supply MD ' 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed l j 5v t it PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here � VD.- ►�: ".s�RM 30 (�h� W \l HOBBS 8 WARREN M THE COMMONWEALTH OF MASSACHUSETTS \ �� � O OARD OF HEALTH 4�--b6z- I V`c Ic� CITY/TOWN o DEPARTMENT ADDRESS �M TELEPHONE Address__- 351 O« Psi ----- —_ --Occupant-_--a 1 _J�AK_n k-1 Floor Apartment No.---.-. No.of Occupants_ No. of Habitable Rooms No.Sleeping Rooms_ No.dwelling or rooming units .N o.Stories � Name and address of owner �or__ wC _ I q 6 L I L P_(,te_r � Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish "\ 2?, Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: CP,,It 1 o o --7 e�) Obst'n.: O+v,_ S,-'es. O LC 5 Y,-,Its/- 6eA ca M Hall, Floor,Wall,Ceiling: d ,� /1-S - /c Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vents ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom —Pantry Den —Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties.- Kitchen Facilities Sink , a J— LPD Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted NOVa{" 'ems He-- Locks on Doors: 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 OF PERJURY." ii)) INSPECTOR_ MU&— TITLE Dire 1-1'__ _ A. DATE /�/O�v TIME A.M. THE NEXT SCHEDULED REINSPECTION A P.M. L x,«. i+i`r„""'""''r^-+`'"`" t;�'"--"'''f��+:�'�4p��.Taw--r:.•-n,.....cep-••-"'^Ya"�' .-.�+ti•'>�f,M.=��Y.�+s...^�.,.*rn•�^...:,�-a..,w'�.Me`�a.+r.r�.K.2..�-Y�. 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 health, 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 II, 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 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. FORf&30 — HOBBS&WARREN'M THE COMMONWEALTH OF MASSACHUSETTS •` BOARD OF H-E-AUTH CI Y/TOWN _ !� W DEPARTMENT ADDRESS G,,M SVey`eW ONE 1551 TELEP Address — Occupan Floor Apartment No. No. of Occupants No.of Habitable Rooms No.Sleeping Rooms— No. dwelling or rooming un No. rieo- Name and address of owner 14(ps Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: VV BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: - STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows.- HEATING Chimneys: Central ❑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.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom(1). Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: ARks, FI ,Ven Safeties: Kitchen Facilities Sink S e Bathing,Toilet Faciil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n.- General Building Posted Locks on Doors: 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 INSPEC ' (See Over) "THIS INSPECTIO EP FIT IS SIGNED AND CERTIFIED UNDER T41E PAINS AND PENALTIES OF P �, INSPECTOR TITLE q� A.M. DATE v TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. � ^ � 410.750: Conditions Deemed to-Endanger or Impair' Health or Safety The following conditions, when found Vz exist in residential premises, shall bo deemed ' conditions which may endanger ov impair the heuhh, or safety and well-being of 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||. 105 CIVIR 410.1001hmugh 410.020otate 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 aaa 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 Vo order repair orcorrection of such violation(s) pursuant to 105 SMR 410.830thmugh 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. KQ Failure to provide uaupp|y of water sufficient in quantity, pressure and tempemtum, both hot and oo|d, to meet the ordinary needs of the occupant in accordance with 105 CIVIR 410.180 and 410.190 for a period of 24 hours or longer. � (B) Failure to provide heat as required by 105 CIVIR 410201 or improper venting or use ofuspace heater orwater heater as � prohibited by 1O5CIVIR41O.2O0(B)and 410.2U2. � (C) Shutoff and/or failure to nmVoro electricity orgas. (D) Failure 10 provide the electrical facilities required by1U5CIVIR410.25O(B). 41O.251(\). 41O.253 and the lighting in com- mon arearequied by 105CIVIR410.254 (E) Failure 10 provide a safe oupply`o water. . (F) Failure to provide a toilet and maintain u sewage disposal system in operable condition as required by 105CIVIR 41O.15U(A)(1)and 41U.300. � (G) Failure Vu provide hn the obstruction of any exit, passageway o,common area caused by any object, � � including garbage or trash, which prevents egress Iin case cdun emergency 105CMR41O.45O. 41O.451 and 41O.452. � � � (H) Failure V»comply with the security requirements of 105CIVIR 410.480(D). � (|) Failure 10 comply with any provisions of1O5CMR41O.S0U. 41O.S01or410.002 which results in any accumulation ofgar- 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 or0oJhocreation or spread of disease. � .k` of i dwelling dwelling 8i violation of Massachusetts Department � �> The presence par�onao�o ngm ngun in e �auoao u epa e Health Regulations for Lead Poisoning Prevention and Control, 105CWR400.000. (See M.G.Lo. 111 @@) 1SO through 19Ql � (K) Rmd,foundahon, ox other otru6tune|defects that may expose the occupant or anyone else Vofire, bumo, ohook, accident or other dangers or impairment Vo health orsafety. (L) Failure to install eleotrimd, plumbing, heating and gas-burning facilities in accordance with accepted p|umbing, hoadng, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CIVIR 410.351 and41U.352. | ooaoVo expose the occupant or anyone else tofire, bumn, ohook, accident or other danger or impairment to health or safety. � (M) Any defect in asbestos material used as insulation or covering on a pipo, boiler or furnace which may result inthe release of asbestos dust orwhich may result inthe release of powdeed, crumbled o/pulverized asbestos material in violation of 105 CIVIR41U.353. (N) Failure to provide a smoke detector required by 105 CIVIR 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 orconditions: ^ (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 CIVIR 410 15O(A)(2)and 41O.150(A)(3)orany 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, houUng, gunfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain aoafe handrail or protective railing for every stairway, porch ba|oony, roof orsimilar place as � required by 1O5CMR41O.503(A)and 410.503(B). ^ (5) Failure Vo eliminate rodents, 000knxachem, insect infestations and other pests aorequired by 105CIVIR 410.550. (P) Any other violation of 105 CIVIR 410i000 not enumerated in 185 CIVIR 410i750KV through ( })shall be deemed to be a con- dition whinhmayondangerormatorial|yimpoir1hehoahhoroafetyandwel|'boingotan000upantuponthehai|uveof1hamwnor � to remedy said condition within the time no ordered by the Board ofHealth. ' . ^ ' \ | ' | I TOWN OF BARNSTABLE LOCATION 3S f U 5J kngEWAGE # VILLAGE 1 4�/V- �( SSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 44177 13/D SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS__-'�__PRIVATE WELI. OR PUBLIC WATER ' BUILDER OR OWNER DATE PERMIT ISSUED: ,�// DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No �— � 4 r- TOWN O,F�sBARNSTABLE 4f LOCATION l a 12 l/ o �T SWAGE # ` 47 VILLAGE R /VS �►I�� SSESSOR'S MAP & LOT O INSTALLL•R'S NAME & PHONE NO. V `� J�y9 'U 14 77 O3/O SEPTIC TANK CAPACITY . LEACHING FACILITY:(type size) NO. OF BEDROOMS. PRIVATE WELL. OR PUBLIC WATER BUILDER OR OWNER ', DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED.- VA RIANCE GRANTED: Yes No f � � � .+� �- -`_ � � _ t ti ,�l � � 3 � � !� �- � � ` { T No. Fee THE COMMONWEALTH OF MASSACHUSETT Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS es \ l pplication for ��otaY �p�tem Congtructton permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or t No. is Name, and Tel.No. / '/ Assessor's Map/Parcel 05 sow M A Installer's Name,Address,and Tel.No. L�rl j), 9 Designer's Name,Address and Tel.No. t�' �! i1 1� ����� �'1L�� 3 , 0 Type of Building: Dwelling No.of Bedrooms 3 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 �3 5 O gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank -:fir`' L-g aOO cc f. Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 17R 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 iss. d o e It a Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ;ice/-•.� yea i` . . ,. No. , '�. ,�'._ 'Fee THE COMMONWEALTH OF MASSACHUSETT I �Entered in com uteri G i• es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS, , f• ' 0(pplication for Migoml *pgtem Construction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Ut No/ ole PO �� is N Ac}dress and Tel.No. 3-5 �7 /l"�'—G ems. K r-o n.e Assessor's Map/Parcel ©;7 . rN—'C^ Installer's Name,Address,and Tel.No. Lie? Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 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 550 gallons. Plan Date Number of sheets �• Revision Date Title _4 _.: Size of Septic Tank Gex�' j /DO©$4 1. Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Y2� O 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 issu d o e lth. Signed , " Date - Application Approved by �>�`�� Date Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that-the -site l.S,ewage Disposal S Istem'Cbnstructed( )Repaired ( )Upgraded ( ) Abandoned( )by� :� rr J J _ � �_ _ > (1 f fl o IU� )_ Leeconstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2dated Installer Designer__ ! , The issuance of this permit shall no -'e cons edfs a guarantee that thssze�m will function,a/s designredI Date J � �v/ Inspector/! li� ,[ ,� / 0 - �_ 1 y---------------------------------— No. Fee s: r 7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 33igpoml *potem Construction Vermit Permission is hereby granted to Construct( ) epai )Upgra e( ) an on( System located at p and as described in the above Application for Disposal System Construction Permit. The applicant comply with Title 5 and the following local provisions or special conditions. Provided:Construction mu be c fn let d within. � r-9 Date: t 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the ma.�dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surf Elevation(using GIS information) B + G.W.Elevation � the MAY. High G.W. Adjustment — /2 DIFFERENCE BETWEEN A and B SIGNED / DATE: [Sketch proposed plan of system on back]. q:health folder.cert l Sewage Permit No. Location: >r ABC Dza AWE- &AP' Village: /{!j�• Installer's Name & Address PEN Builder's Name & Address ia►s! MZ S"&Ae wW,Sr NA. 0 Date Permit Issued /2 Lvrlo% ©Date Compliance Issued u i GA-L } A �'tC No.._ �7.�......77.� r .ti... FEs. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ®. Yl .........OF.....- ,T7 3� .. Appliraa#ion for 11hipati al Works Corm rnrtiun ramit Application is hereby made f r a Permit to Construct (i-�or Repair ( ) an Individual Sewage Disposal System at: . 7 04-P ................RO...S.. ........ ..., . Z0� . ................. ........_ Lt ........................................... Location-Address o .... 'r,e�L�l/ �IC.SZ/ .......................................... -G�71i/4//S f'1�s�S =........................... er Address a •......................... . •••....................................... ......•••---••--••------•--- Installer Address Type of Building Size Lot.. /.:�.......Sq. feet U Dwelling—No. of Bedrooms...............3.........................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures --.-------•----------------- - W Design Flow..............?37.--.....................gallons per person per day. Total daily flow._._.._......33 .....................gallons. WSeptic Tank—Liquid capacity.�a®e_.gallons Length..-•-s``..... WidthA�`-""... Diameter................ Depth..J:'.��-- x Disposal Trench—No..................... Width.................... Total Length................... Total leaching area....................sq. ft. Seepage Pit No...... ............ Diameter.......f�!...... Depth below inlet.....!E.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '—' Percolation Test Results Performed bs � ..:: P�^--•--------•--__ Date._ Y �.. ,aa Test Pit No. 14JIAOn_.minutes per inch Depth of Test Pit--- ..... Depth to ground water.................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------------------------------------------------------•----•---........._.....-•----•------•---........................................................ O Description of Soil..-03 '�--, 4 - "`.g` ' U ---- ------------------•--•--•--`1---D>�+!-------Cv---------T__•S'A-.ems -------- •------------------------------------ ------------------------ .---•--••---•----------- W ••••------•-----....---•----------------•-------------•-----------------•-------•-....••--••--•---•--------------------------------------------------------------------•------------------------••-•---- UNature of Repairs or Alterations—Answer when applicable............................................................................................... L.......................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1,14. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed....... .............&.... ... .... ................................. ................................ p� Date Application Approved By...... ----•-----------•- .............. = ----------- Date Application Disapproved for the following reasons:-----•------------------------••----•-------------------------•-------------•--•----------------..----......... .....................................•-....--•---•-•------------•---------------•••••--------•-.......•. Date PermitNo......................................................... Issued....................................................... Date L � I THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH .............. ...............------------...........----...................--- Application is hereby made for a Permit to Construct (L,15-or Repair ( ) an Individual Sewage Disposal System at: _....... cl -------------------- ---------------------- ............................ Location-Address or Lot No. ....`....° Y:/.._. e. �r- .....-....� .'1�3 ... ....................•-•............. ---•........................................ r......••••--•• ......_ Owner Address W Installer Address Q Type of Building Size .........Sq. feet Dwelling—No. of Bedrooms.............. .........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .. No. of persons:! ............. Showers a YP g ---------------•---•-----• P ----- ( — Cafeteria ( ) 04 Other fixtures -----------•----•--------------------------•------••--••-•---•-•--........................................................ W Design Flow............ �..............................gallons per person per day. Total daily flow..........._�...0 ........._ WSeptic Tank—Liquid capacity_�egU_.gallons Length.4..'`.___. Width.'�''e."... Diameter................ Depth._S..8 x Disposal Trench_No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......1------------- Diameter.......?o......... Depth below inlet.... .......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ `-' Percolation Test Results Performed by. °-7A>__ ___.teeZ4L-!'._ ' :................. Date.__ �%T• Z ` .... ............ Test Pit No. 14.-1?7A!n..minutes per inch Depth of Test Pit...�' '_..... Depth to ground water.......-............. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ...........*-----------------------•-------------..-.......•........------------------------•--------.............----......--------------•------ O Description of Soil.... "3 .`1_..1.e1 •. ` Svr�:So i =4"— 49.................. �ry��+te--L . . -•--•- UTu�T. S�-....i� W ------------------------------------------•-------------•------------------•----------------.......----------------------------------...-----------••--•--------------------................--•---.•••- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•------------------------------•-----------.........------............----.....------------------------....--•--------------------............._.......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sighedn:. A ------------------------------------------- .._..._ 12 ApplicationApproved By........................................................ ...................................._ Date Application Disapproved for the following reasons-----------------------------•------•---•--------------••------------------------------......................... -•.......•••••••••-••.................•••.....•-••••---••••-•-••-•-•-•--...---•••-••-•-•-•-•-•••-•-••••----•••-•---•------•-•----...------•-•------•-•••••••---•----•-••••--•-••----••---••••---•••-•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TL3(n<<.✓........OF..........^............:.:r...............................I...................... .................................. � � r�ifirtt� ,af f�u�t��ttt�tr�e �� THIS IS T CERTI�kk y a�the Individual Sewage Dis osal System constructed or Repaired by- ;70 y✓ 113 r "mil Installer at...................................................................................................................................................................................................... has been installed in accordance with the provisions of TI` `" ....j o? State Sanitary 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.............................................. - �.=1 ................ Inspector..................................-0.0-.4L................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H4 EALTH .................��..^:�. t.......0F...../a.��%nfr:T.�i C. C.. ............................... No......................... FEE........................ Permission is hereby granted........ •--•••�--; , --------------------------...................................... to Construct"� W` epair j Iwi4gt St age isposa`I'"Sy9 e n' atNo....................................... ...........................................................-------------•-•--•-•-.....----•••--•---••--•..........--••••......-••-•••....-•-......... Street as shown on the application for Disposal Works Construction er F t o.1�- ---••------------:------9..... ✓•'�i Board of Health DATE.................- �... ................................................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERSr�, (a i 7 I v t, 4 � �i ty�' � t�q•� v q e r pay.+ares j�+�..rrt,c -�.�'.�i✓r,�,F � � 4 ���' i � F' '_ /.SST �� �dS✓yTT .*— tti' G .36. Q 1 Qt l 9 1 + 4-8« mac.. 9 7 z t _ _t, a f�A '10 \ /V1.EAvM r f . a 89• Z .�rl vL �', Nl✓ d MWIMUM ojax t '1615G1f SGAL� —��f_ 3 o ' 30 ' '00t4T IS ' GI PE, —Zs'L jZEAV- 0 �4UNVA 10 /&AN H O L TO D o flNls►4 Cacz,o►M MW. 2°10 WIT404 ONE. FOOT OF O ISH GRAVS OVER LEAGH AREA � a#''vtA.. COti�IyC "iNti�K�+t��T�N� l -� sox ' .%4" rnFN. /Fortf prrw F 1►JFtL?f2A1'ttJ�a NE � Mlrl� N I . P G rf - 6't 1PO�I Z7^0JL - T I +Z !A do W.".40 f4a - wow IPM � _ J— t tdM►N, q. T a/moo,- (NUN. S'4 F00r �, �• o �rA--1/Za1A. --. v i ,Ec./OB,x I 1.EA�H STONG° lt+N�RT GA-�t.�.4 y 4'PAII.1 1 ►t�v ar r1 + aT PIA. V.C. IN�R1' PI wA rsg ) Ec-�07so ��o I 6lz� I 41 _ 5EP'i'+c. sYSTEnn coN s-tR UcTroN �,: `�I 5�{ALL CONFORM TO THE MASS. ,�� HumliP�� OF ep�O Room —— —— — �tJ�Jt RONMENTAL CODE TITLE$ Aga: `s.. . REV ISev 7- 1-77 Ty I-HE -MVOJ ; �' r E- D�GjIG11J FL0�I 00AW of NS►1.'t1-4 REcaU6,AT►0t49 r. �_� s �7 NO , tLeACN1N6a RATS. i SEPTIG'fANK, PISTRt C�tJT►oN poll ` '"��•. � ` .,�f��AN 17 LEAOM ttJl,-I ?IT TO C3> oOF— R EQ �O. i,6AC 4. M�rN. co,�c.2 tr �-i Nci't1.13ouoP�► PiZOPoSED LEAGN CAeACJV Gf AFL rt 2 P51 2.S 6-- Trio ' 1. 0 7L6 H 10 LOA01 (4CA xe pRtJsJR)/ Nor -ro 0E LOCA MV f� i/"k •.. ; 125y14aN LoAPIWCa ALA- PI P5-4F7-'o Oe WATF-R.'fi44 H-r 5y5r -tb S a�i ' eA,�� 'ti OARNd,, Rom. of DEEDS 'Fad • -- _ _._ T-E LA ' 'E 5 o GA t O� C�► nA — '-=3 z� — -- ENGINEERING o .o DESIGNING BUILDING —— -- --- — — — -- -- x INC. �a1.. o � 46AI-Tk A6 APP9 DENNIS, MASS. I