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HomeMy WebLinkAbout0265 OST.-W.BARN. RD - Health C; 265' �• •���n '�C R `MARSTONS-MILLS A= 121 -005 / 1 Number Fee 1008 THE COMMONWEALTH OF MASSACHUSETTS $loo.00 Town of Barnstable Board of Health This is to Certify that Auto Diagnostics 265 Ost-West Barnstable Rd., MA 02655 Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. --------------------------------------------------------------------------------------------------------------------------- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires June 30, 2008 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN SUMNER KAUFMAN,M.S.P.H. 7/9/2007 PAUL J. CANNIFF, D.M.D. THOMAS A. MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable oft :Regulatory Services Thomas F.Geiler,Director MASS.= Public Health Division _. '°r�aM►•� Thomas McKean,_Director. ' 200 Main Street, Hyannis,MA 02601 .0ffiee: 508-862-4644 Fax:.508-790-6304 Application Fee: $100.00 r.s ASSESSORS MAP AND PARCEL NO. DATE ! c c APPLICATION FOR PERMIT TO STORE AND/OR UTILIg MORE THAN III GALLONS OF HAZARDOUS MATERIAL M FULL NAME OF APPLICANT NAME OF:ESTABLISHMENT el f-o ADDRESS-OF ESTABLISHMENT' L_ TELEPHONE NUMBER e>lJ g 7 7/ O SOLE OWNER: YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. 0 43 9) STATE OF INCORPORATION 13 CD6ZOC\';' W\° FULL NAME AND HOME ADDRESS OF: n PRESIDENT aft KA C_ �K� Q Ma 0a6S TREASURER Sri►MQ CLERK — SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS a6�DSJ � • ��2r1 ��` boa HOME TELEPHONE# j aw 30 �►�Sdn a60 I y, ' jd r Ks U�-6.p Vl 6�S mg, ; V Number Fee 865 THE COMMONWEALTH OF MASSACHUSETTS $1oo.00 Town of Barnstable Board of Health This is to Certify that Mid-Way Garage LLC 981 Main Street, MA 02655 Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. ---------------------------------------------------------------------------------------------------- -------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires June 30, 2008 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN SUMNER KAUFMAN,M.S.P.H. 7/1/2007 PAULJ. CANNIFF,D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable opt Regulatory Services Thomas F. Geiler,Director M" AE%.M Public Health Division .Q bIA93. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Application Fee: $100.00 C ASSESSORS MAP AND PARCEL NO. I DATE c5 TIP �n, (' co APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE ORL R' THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANTa►A,e-\ V65�2 NAME OF ESTABLISHMENT Q C�n.0 L L C ADDRESS OF ESTABLISHMENT TELEPHONE NUMBER SOLE OWNER: YES.X_NO IF APPLICANT IS A PARTNERSHIP, FULL NAME AND HOME ADDRESS OF ALL TNERS: n _ C cltY� 0�lp�S IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION TY) A 5S FULL NAME AND HOME ADDRESS OF: PRESIDENT RN C�,\, rc� TREASURER 3)< 6k L\ C \-\(vv A �' CLERKt SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS tks '� R . - 00' v"` e— od t�S s HOME TELEPHONE 4 Sbg `� MidWay Garage LLC 981 Main St Osterville—MA 508 420-7220 Spill Procedure Plan • Evacuate the immediate area, if necessary. • Shut off valves, pumps, and electrical equipment as appropriate. • Remove or restrict any potential ignition source from the area is the material is flammable. • Cover or dike all existing sumps, and storm drains if not already covered. • Contain the spill by use of absorbent socks/booms,them apply appropriate absorbent material. • Contact spill response firms, if necessary,to assist in these activities. • Remove all absorbed material or contained liquid and package in DOT approved container. Used absorbent materials should be packaged separately from liquids. • Label all containers with the type of waste and the start date of accumulation. • Notify the appropriate agencies. • Once the spill has been controlled and materials collected and secured, inspect the area for cleanliness and decontaminate all equipment used in the clean up. • Replace all used materials and ensure all response equipment is in good working condition. • Manage and dispose of collected absorbents and liquid in accordance with Federal and State environmental regulations. • Manage and dispose of collected absorbents and liquid in accordance with Federal and State environmental regulations. • For any spill greater then the reportable quantity or 25 gallons, whichever is less,this plan shall be implemented and proper records on action shall be kept on-site. • Spill clean up equipment is located is the garage. • The following is a list of the equipment on site: o Spill response kit o Fire extinguishers o First aid kit MidWay Garage LLC 981 Main St Osterville—MA 508 420-7220 Emergency Services Fire Department: 508 790-2375 508 862-5235 Police Department: 508 775-0387 DEP Office: 888 340-1133 617 338-2255 CIA (Corp. Env. Adv.): 800 358-7960 CYN Environmental: 800 242-5818 SPLASH: 800 746-3835 00 0.83: .. ... FimBA...10.oo........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ....................Tom._...........OF........Barns .able..... r. ApplirFa#ion for Dispaii al Works Tomitrurtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 265 West Barnstable Rd. Osterville MA 026 = Location-Address or Lot No. Diane M. Gray 26 West Barnstable Rd. .__-Osterv ],le 02655 Owper Address aA & B Cesspool Service12Bos eac ..H ya . 026 p • .. ..... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............ ..............................Expansion Attic ( ) Garbage Grinder ( ) a4 Other—T e of Building No. of persons.............3.._..__..... Showers — YP g -------------•-•--•--------- P (----)-------Cafeteria ( ) dOther fixtures -------------------------------•----------....------...------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow....................................._._....gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Dep-,h................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 4 Test Pit No. 1................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........................ ►x ----------------------------------------- --...... •----------- .....----- ........ .... .------------._.------------------ ....... .----------. -------_....... ..-- O Description of Soil...-Sand-------•--•..................................................•-------------------------------------------------...----------------------------------•----- x U .---------------------------------------------------••-•--------•----------------------------------------•-----------------------------------------------•-------------------------•--------------------- w UNature of Repairs or Alterations—Answer when applicable...insta.11ataon---of:..a,-_1.,.00D--gallcn.y-..pre—oast ....stone---PaQked_.1eaQh_.Pit...(. verf1-aa)----------------•----•-------------------------------------•--------•-------------•-------------------------...------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'L LE 5 of the State Sanitary Code— The undersig furth s not to la e the system in operation until a Certificate of Compliance h ee s y the bo d Signed_ ....... ....... •-----...... -- -- . --------ICZ�/a3----- ate ApplicationApproved By............................................................................. ----•-------------• ----------------1ja26/a3----- ate Application Disapproved for the following reasons---------------•-----------------------------------------------•-----------------•----------------------...---•-- .....................•-----------•-------.....--------------•---------------------------....--------.......------.....------.------------------....--------------------------------------------.......__ Date Permit No...........83........................................ Issued•.................10/26/83-•-•--------------- Date l _ J lk No.-g3_ .... .. FRE4....L0• 0...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................Tawrrt........._OF..........Rae'i9S �b�e... ...........---------•----......--•---...... Appliration for Uispnaal Works Tomuurfiun runfit Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at: 5 des k.-•I3a. + a is •} -0s a ?le I► { �5 --------------------------•------------•-----------------------............-•------- �. - Location-Address or Lot No. ......1)J=e-.VL,•..C7a-y..........................................•---------------- 2�;5-�isss .-a�. t�?�1$ i......�It�v:���141... --A--- 02655 Owner Address t aA-.&-B-.Ce ssRojol..;3eei:uirae....................................... ---1:2R--R_i 8h0s �M60y... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............3............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons________________ __________ Showers — Cafeteria Q' Other fixtures -------------------------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................. x Disposal Trench—No..................... Width.................... Total Length.........._......... Total leaching area....................sq. ft. Seepage Pit No Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) - aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.___-___-__-___----____. �+ ----------------------------------------------------------------------------------------------------........................................................ 0 Description of Soil.....Sand----------------------------------------------------- x W --•-----•--•-----------------•---•--------------•--•------•---------•-----------------•-------------...•-•----------------••-•----••----------•------•---•-•----------------------•-----•---•----------. UNature of Re?airs or Alterations—Answer when applicable.—.-- &a1lat4-on--- -.---stene... acked-••leaeh •p#t--{everflcw-} -----------•---------•--•--------------------•-•--------------------------------------•--------------------•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System p-accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to;place the system in operation until a Certificate of Compliance hW>l ei,/ s by the b r-�p~f iealfh: ,1 Signed ...... ............... - J D'�te Application Approved By.................................................................... �' 1 Dat?Fi`8 Application Disapproved for the following reasons----------------•----•--•-----------------------------------------------------------------------------..._....._ ---------------------•-------•--------------•---------------...-----------------------......------------.-----•-------------•-•-------•----•-------•---••------•------•-••---•---------•---------------- Date Permit No.............83-..................................... Issued...................1Q/2G/8.3................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................Tom...........OF...........Z?a1`�'.�3-ta-b1-2............................................... Trrtifiratr of Tontpliancr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by........- ....................................... Installer at.._2b .1c79 __?axn. tea l ,8d O +.e vl11e.,--�- -----02655.._=.-Mane..S. �' �! has been installed in accordance with the provisions of TIT L=, 5 f The State Sanitary Code as described in the application for Disposal Works Construction Permit No.- -_/............... dated.......1-0/26./83...................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT>BECONSTRUED A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........----10-7183................................................ Inspec --.---• ------------------------------------------------._......-•-.----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH m.et�r�L.........OF.................Ra7st h7 � , .e No....... .'U�� ........ FEE......:::1..00... Disposal Workii Tilus#rudion amit Permission is hereby granted-------- ------- .-----------...-----------.........------------.............--•--........ to Construct ( ) -or Repair ( x) an Individual Sewage Disposal System at No. �h5 e t__P�arnst�ah7 e..-4dx,...Os+e till s r'� 0 55 - • Y----------------------------•--..... Street as shown on the application for Disposal Works Construction Permit No ,�. 1_._.��Dated....................1-0/26/83... ............. -•---- ---------------------_--.-------------------------•-------- ,, Board of Health DATE 10127. ..83--------------------------•-•----....-------- ' FORM 1255 HOBBS & WARREN. INC., PUBLISHERS No. �T3 d Fee$50 .00 THE.COMMONWEALTH OF MASSACHUSETTS•V ' / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS v 01ppYicatiou for �Digogal *pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair(x:�an On-site Sewage Disposal System at: Location Address or Lot No. 265 Osterville — Owner's Name,Address and Tel.No. 4 2 0—61 4 4 West Barnstable Road Diane Mitrano 265 Osterville - Osterville, MA 02655 W Barnstable Rd Osterville Cp Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Sry PO Box 1089 , Centerville, MA 026 2 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( n6 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil �a n d Nature of Repairs or Alterations(Answer when applicable) consisting of 1500 g septic tank, D-Box, and title 5 leachin4 system, to accomodate 3 bedrooms. '°$ �Ai g-6 h!!-;, �/ •� 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 thi of Health. Signed Date Application Approved by l� r Application Disapproved for the following reasons j Permit No. V411- Date Issued TOWN OF B STABLE rN SEWAGE # LOCATION VILLAGE ASSESSOR'S MAP&LOT ` R'S NAME NO &PHONE . a �1STALLE �grn SEPTIC TANK CAPACITY size LEACHING FACILITY: (type) ( )NO.OF BEDROOMS BUILDER OR OWNER n ATE: �—/ y PERMITDATE: / _I!` COMPLIANCE D , Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) exist Edge of Wetland and Leaching Facility(If any Feet within 300 feet of leaching facility) Furnished by t� i �• J l � � _ - No. Fee 5 0.0 0 THE>C�OMMONWEALTH OF MASSACHUSE17 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS _ f A 1pprfcation for Migool *pgtem Coriotruction,Permit Application is hereby made,,for a Permit to Construct( )or Repair(X2¢an On-site Sewage Disposal System at: 41 Location Address or Lot No. 2 6 5 O S tervi 1 l e — Owner's Name,Address and Tel.No. 4 2 0—614 4 (il West Barnstable Road Diane Mitrano 265 Osterville - 1 Osterville, MA 02655 W Barnstable Rd Osterville Installer's Name,Adcress,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Sry PO Box 1089, Centerville, MA 026 2 Type of Building: I Dwelling No.of Bedrooms 3 Garbage Grinder( n6 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures T Design Flow gallons per day. Calculated daily flow gallons. Plan Date. Number of sheets Revision Date Title Description of Soil sand Nat re of Repairs or Alterations(Answer when applicable) consistingof Y500 g septic tank, D-Box, and title 5 leachin4 s stem to accomodr e 3 bedrooms. b — �./ b he?-p> /l a-S - a' Date last inspecte / Agreement: The under,igned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance w4h 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 th• of.Health. n Signed Date `��"'� 7 Application Approved by L 7 Application Disapproved for the following reasons Permit No. � /` Date Issued 1, 1 . -' EOMMONWEALTH OF MASS CH4TTS! PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mitrano Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(x )on by Wm E Robinson Sr Sent. Srv._ for as 265 Osterville - W Barnstable Rd, Oster.vi_ll ie has ben constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 7— Use of this system is conditioned on comgljance with the provisions set forth below: C �f Installer: WA E Robin;oA sr septic Rrir No. 9 Fes-5-0 0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS wigo5ar *pgtem Construction J)ermit Permission is hereby granted to WE E Robinson Sr Septic Service .,, _to construct( )repairkx )an On-site Sewage System located at 265 Osterville-W Barnstable RT Osterville, MA 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. All construction must be completed within two years of the date below. Date: % Approved by V'"' ['C YY, !` 1(✓t" �1^ Aer: I f NMWE: T-hinp form-is-to-be-used-fortk repzh:Qf faifed- septic-systems-only CERTIMYN:OT-n=MANDF APPLICUMN FOR A DWMAL V4� - RKS-E-QNSTRUETION-PERMIT M THOU-T RESfGNEDTLANS) -@ritnm-L: Robinson, Sr. ,herebycertif -that theation forspr�saorks eonsfistien-peniit-sad by me dated- 2 - 4-`°1 7,concernOtg the PmPerLX-kZcate&at:.. 2 SfL%tmiffe_- Rarnct-abk:Rzf ()AcrviHe,_M _ mepts all of the erite4a. 1 are-twwetFan&aHhh'3tt( &eLoUffieTropose_ fcenfiC Stem. - -I aM-Rc�-ovate--wtUs- -Mfeet4ftkeproposed-septic-st rstem. he- table is-14 mt or greater-below t -bottom of the k4c4ing-f*cility. no-increase is flow and/or rehange-i-ww osed. *-' there- re`nwvariances-requested or deeded. rlJZEh= na r-arrEIUM=TOWY a TA=N 60 (Attach-a sketch-plan-oftbe pr-opesed,Vst . Also-if the-lisnsed-instller proposes a-ce eion plot ply this plan should be su*itted). a d i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS l v% DEPARTMENT OF ENVIRONMENTAL PROTECTION a v R ~ r r is yew TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Owner's Name: MR.MITRANO RECEIVED Owner's Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Date of Inspection: 12/4/00 CJ C.E✓ 8 2000 Name of Inspector: (please print) JOHN GRACI TOWN OF BARNSTABLE Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the"time,of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.3401ad Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs Furth valuation by the Local Approving Authority Fails Inspector's Signature: Date: 12/4/00 The system inspector shall submit 1copy 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 now 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 SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFULL LIFE. a. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how'the system will perform in the future under the same or different conditions of use. i r! I . Title S 1ncnrr6nn Fnrm 6i1 snnnn IPage2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A is CERTIFICATION (continued) Property Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Owner: MR.MITRANO Date of Inspection: 12/4/00 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: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. 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 orjepair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,NND)in the for the following statements. If"not determined"please explain. n/a 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: n/a n/a Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is`removed _ 'distribution box is leveled or replaced .; ND explain: n/a n/a 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: n/a i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Owner: MR.MITRANO Date of Inspection: 12/4/00 C. Further Evaluation is Required by the Board of Health: y, _ 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: I _ 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. C , _ 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 tos determine distance n/a "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 6this form. F 3. Other: n/a 4 w,i t.api icd Z 1 l . Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Owner: MR MITRANO Date of Inspection: 12/4/00 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 NnT due to clogged or obstructed pipe(s).Number of times pumped nla. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool*"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.] (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. i.. 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered 's, "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. ;f 4 Lt Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Owner: MR. MITRANO Date of Inspection: 12/4/00 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 th-.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)] e i Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Owner: MR.MITRANO Date of Inspection: 12/4/00 FLOW CONDITIONS RESIDENTiIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203"(for example: 110 gpd x#of bedrooms):330 Number of current residents:2 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] Laundry system inspected(yes or no): NO Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203):.n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO , Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--H©vi was quantity pumped determined?n/a Reason for pumping: n/a 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(describe): n/a Approximate age of all components,., ate installed(if known)and source of information: 1997-PERMIT97-348 Were sewage odors detected when arriving at the site(yes or no): NO 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Owner: MR.MITRANO Date of Inspection: 12/4/00 BUILDING SEWER(locate on site plan) Depth below grade: 14" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 8" Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions; 150OG L 10' 6"H 5' 6" W.54 8"" Sludge depth: 1" Distance frcm top of sludge to bottom of outlet tee or baffle:33" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a . How were dimensions determined: MEASURED Comments ion pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a , Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.),*,, n/a .i� Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Owner: MR.MITRANO Date of Inspection: 12/4/00 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) t Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): , n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): A ' THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no):NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 265 WEST BARNSTABLE RI)OSTERVILLE,MA 02655 Owner: MR.MITRANO Date of Inspection: 12/4/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a INFULTRATORS leaching chambers, number: 3 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) } Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a 4 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Owner: MR.MITRANO Date of Inspection: 12/4/00 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. IA 0 AA �3 k a6 •�� 3 �M�: � fly i Y 1 i in Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 265 WEST BARNSTABLE RD OSTERVILLE,MA 02655 Owner: MR.MITRANO Date of Inspection: 12/4/00 SITE EXAM _Slope _Surface water _Check cellar Shallow welts Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) YES .Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET ',zsa x Q�J f W'4'04-1Yf-;Q-,TOWN OF BARN/S,T�ABLE�;�-����� ,LOCATION 1Z, 16 ,<L � .��dW/ SEWAGE # T VILLAGE 0 S t ASSESSOR'S MAP & LOT l d I >da6- INSTALLER'S NAME&PHONE NO. /17d,�,,ALS a� � , SEPTIC TANK CAPACITY .� 7 0 LEACHING FACILITY: (type) �� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTfDATE: / / `' 9 --7 COMPLIANCE DATE: 9 " /% 2 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 I Furnished by r U 44 . `-LOCATION SEWAGE PERMIT NO. 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