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, ASSESSOR'S MAP&PARCEL
0�4*='S NAME&PHONE NO.r;;:4 3 N e-L
SEPTIC TANK CAPACITY 1��
LEACHING FACILITY.(type) yr f�,ITrc.T®rS (size)
NO.OF BEDROOMS
OWNER l.ur Lev
PERMIT DATE: �E DATE:M R oklo y
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 lea5Wnglacility) Feet .
FURNISHED BY
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
o
w 154 Prince Avenue, I
Property Address _
Mark Curley
Owner Owner's Name,
information is Marstons Mills MA. 02648 May 6, 2009
required for State Zip Code Dale of Inspection
every page. Cityrrown S p
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information -
When filling out V
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. —Septic Inspection Services Co.
Company Name
r� 189 Cammett Road
Company Address
Marstons Mills MA 02648
renm City/Town State Zip Code
508-428-1779 SI 12855
Telephone Number License Number
B.-Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs.Further Evaluation by th Local Approving Authority
May 6 2009
In ector'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.
****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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
09.75 Curley.doc-08106 h
t�
i
Com Ionwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I
154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is IMA 02648 May 6 2009
required for Marstons Mills
every page. Cityrrownl State Zip Code Date of Inspection
k
B. COrtification (cont.)
I'
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Tank is not in need of pumping at this time, infiltrators show no signs of backup or saturation.
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
09-75 Curley.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsu ace Sewage Disposal System Form -Not for Voluntary Assessments
w 154 Prir ce Avenue
Property Address
Mark Curley
Owner Owner's Name
information is Marstons Mills MA 02648 May 6, 2009
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
❑ Y q P P 9
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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.
09-75 Curley.doc•08106 i Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 15
i
I
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is Marstons Mills MA 02648 May 6 2009
required for
State Zip Code Date of Inspection
every page. City/Town
i
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 indicates absent 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" orl"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool .
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than_day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
09-75 Curley.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massach
usetts
usetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
154 Prince Avenue
Property Address
Mark Curley -
Owner Owner's Name
information is required for Marstons Mills MA 02648 May 6 2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® 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.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
09-75 Curley.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is Marstons Mills MA 02648 May 6 2009
required for State Zip Code Date of Inspection
every page. City/Town
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ 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:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
09-75 Cudey.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
r
' Commonwealth of Massachusetts
w Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 154 Prince Ave-we
Property Address
Mark Curley
Owner Owner's Name
information is Marstons Mills MA 02648 May 6 2009
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
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
4
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Currently
Last date of occupancy: Occupied
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
09-75 Curley.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is Marstons Mills MA 02648 May 6, 2009
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Tank pumped December 2008
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® 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):
Approximate age of all components, date installed (if known) and source of information:
Compliance date: 11/2/98
Were sewage odors detected when arriving at the site? ❑ Yes ® No
09-75 Cudey.doc•08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 8 of 15
r
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is required for Marstons Mills MA 02648 May 6, 2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
1'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
I
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
------------------------------------------------------------------------------------------------------------------
10.5' long x 5.8'wide- 1500 gal.
Dimensions:
2"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
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
14"
Measured
How were dimensions determined?
09-75 Cudey.doc•08/06 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 9 of 15
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is required for Marstons Mills MA 02648 May 6, 2009
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.).-
Tank is not in need of pumping at this time, liquid level was found at bottom of outlet invert and tees
are intact and clear.
Grease Trap (locate on site plan):
Depth below grade: feet
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: Date
Comments(on pumping. recommerdations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
09.75 Cudey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is required for Marstons Mills MA 02648 May 6, 2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
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.):
No solids or high stains present Liquid level at bottom of outlet pipe.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
09-75 Cudey.doc-08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is Y
required for Marstons Mills MA 02648 May 6, 2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 4 Infiltrators.
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Stone and soils surrounding SAS were probed and no evidence of saturation was found.
09-75 Curley.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is required for Marstons Mills MA 02648 May 6, 2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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 ❑ 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.):
09-75 Curley.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is Marstons Mills MA 02648 May 6, 2009
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.
Front
Water
Service
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
20
43
.<f;,\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 154 Prince Avenue
Property Address
Mark Curley
Owner Owner's Name
information is Marstons Mills MA 02648 May 6, 2009
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam,
® Check Slope
® Surface water
® Check.cellar
® Shallow wells
20
Estimated depth to ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Low area at rear of property with no surface water is considerably lower than SAS.
i
09-75 Curley.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
TOWN OF BARNSTAB.LE
00CATION */ T7 V � (tarr SEWAGE # �76 2
PILLAGE ASSESSOR'S MAP& LOT 0 746-006
INSTALLER'S NAME&PHONE NO. e! kb'46-
SEPTIC TANK CAPACITY Jih B c
LEACHING FACILM: (type)' (size) V a.,.�t 'Y jf�a.R
NO.OF BEDROOMS
BUILDER OR'OWNER .v�
PERMITDATE: -319 - COMPLIANCE DATE:?
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
A '�� �.� '
A-x
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Migozar *potem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade 1r17)Abandon( ) Womplete System El Individual Components
Location Address or Lot No. S Owner's Name,Address and Tel.No.
Assessor's Map/Parcel O v ~\�' (1,Q Aj
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
qvv
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 I�ay STc Type of S.A.S. A%,Ot cr P!!�� C
Description of Soil VII�PQ S
Nature of Repairs or Alterations(Answer when applicable)
C, 1 vim- l~rc ! "Z_ f�v
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 be Issued by this ea th_?,_::�-7
Signed Date 6-.2
Application Approved by Date /d-3f-7- �8
Application Disapproved for the YollowiWg reasons
Permit No. F - 7 6-JL Date Issued
No. — Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zippfication for ]Diopooar &p5tem Conotruction Permit
Application for a Permit to Construct( )Repair( )Upgrade(?<)Abandon( ) LKComplete System El Individual Components
Location Address or Lot No., (( Owner's Name,Address and.Tel.No.
Assessor's Map/Parcel o�� ^�,�-•�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
t(J-G4A`P��(�L v
c•+r (�Q
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
C
Design Flow K13 b gallons per day. Calculated daily flow 3� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ' 0 0 SnT< Type of S.A.S. C�, L--
Description of:,Soil
Nature of Repairs or Alterations(Answer when applicable) f�.S
-516t,c 14 40�
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 untin'Certifi-
cate of Compliance has be issued by this ealth. fir'
Signed Date6=�. '
Application Approved by Date /D-3G— 9a
Application Disapproved for the rollowii reasons.
Permit No. / 7 6 a Date Issued
---------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
*4
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded oc )
Abandoned( )by _ i Q--c 14"'P E. 5 F ((
at vr` f—ce— r Vy t has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. /,?`702 dated
Installer Designer
The issuance of this. ermit shall not be construed as a guarantee that the system will function as designed.
Date — CIO Inspector
<_l
---------------------------------------
No. �0 �7 0.g�_ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Miopogar bpotem Conotruction Permit
f Permission is hereby granted to Construct( )Repair( )Upgrade(Abandon( )
System located at Y/ e. 04-c<f
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: 1 f r 0" Approved by
V'
r
L
t j , 1019/97
T.
F
1
S
F i NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems On
. , lk-
TF I • ;
t. • •~
tCER'MCATtON OF SKETCH AlD APPLICATION
DISPOSAL WORKS CONSTRUCTION PERMWITHOUT
. .
;� :-, l
I (
ENGINEERED PLANS)
{I a
w
hereby certify that the application for disposal works
construction permit signed by me dated I Q '�O � concerning the
rFz, C i �- — meets all of the
ProPe
rty located 8t
following criteria.
; fitere are no wetlands located within 100 feet of the proposed leaching facility
Them are prlrate*dlis within Iso feet of the proposed septic system
6 Theme no in t and/or change in use proposed
� ted or needed.There are��r+egae's
Ifthl prop t►d ftaehii�tg&Cility will be located within 250 t`eet of any wetlands the bottom of the -
-proposed leaching facility will nit be located less than fourteen(14)feet above the maximum adjusted
! _ gronndwsw table efevation. .
y3 .
l leitt eoth lets fht Mlti*lag,
Ll
A)top of Cfo>401d Elevation(according to the Engineering Division G.I.S.map)
^,►
..
Gt'etttidwgte"r Table Elevation(according to Health Division well map) - L6,
!,W MY
y Q (yam DATE:
�Ya,ryx '°., L Y�V��♦ .: ...-. ... ----' i
ell
LICENSED StIMC'9YSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
1 •
eketeh plan of&a prt wed"em•Also if the licensed installer poeessa a certified plot plan,
d
`y ` ,; t,tltil�plan sharid!re nitt�dj: ,,. :
tt
S, }
S
,��� y�s,f !M»�w I�italtA•blNer 6�t .. . . . ��
�f{x
SWi. V�.f.'JMxM.•`Y...,.... .., .. ..-._,.+. E.,.+i+a:.•.wew'.We,U.J .✓e,.,.. .r.«..a, ....... ., ,r.. u . ......a...n.. .. ..... ,+. M »r.Fe.:4Md>." .
I
I�Q V
C
U
1 a� 12 1�-Id
TOWN OF BARNSTABLE
LOCATION SEWAGE# �Q Z
i
VILLAGE t6_ , ASSESSO�R'SD'MAP& LOT 0 76 -00 r,
INSTALLER'S NAME&PHONE NO. R�Tar,e r j e
SEPTIC TANK CAPACITY
LEACHING FACEUN: (type) U ,.,,
'7�� (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 403 0 .U COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
CONTRACT Customer Name_�'V�ti` t ;,,t- L r��•� __ Customer Signature_�M c
• SKETCH Contract Date ��. `>t :% ' 1 __ Sales Representative Signature_ - K—'--
ATTACHMENT Customer Phone_ > '1=`: `_ Contract Price
2 3 4 b 6 7 8 9 10 11 12 13 1a 15 16 11 18 ,9 20 21 22 23 N 25 26 27 28 29 30 31 32 33 31 35 U 37 36 39 40 41a2 J3 n5 <6 a6 +9 50 51 52 -53 5+ 55 56 5) 56 59 fiG
,o t
17
21
It ti
�l -
1
I
23 It -
a \ '
26 �X 13 0.rCG..(EXL�Girc. /�IregJ l �; ?. V
r
31
r.
=,z-5 rts�` rc i ba: t,.�'�� Y 'air_RtY +kr: �rEaMtS
32
33
3c
35
NOTES: 'Each box equals one toot unless otherwise noted.This sketch is a good faith
representation of the work to be done• it is understood-that all dimensions
derived from this sketch are approximate•and that all locations of outlets,light
fixtures,plugs,jacks and/or switches are subject to change it necessary.
M. r,�.r rls 30 �P�G�J
NO P 1�•2=Sf � C��v,o"��.p vSe G( ma`s �1 '�P�XU�t/1� ���(l`�'��,C/��S^`a���JGLP`y,g,��w�l�/ov„f
ga
Y ( I
i
TOWN OF BARNSTABLE - UNDERGRUUND FUEL AND CHEMICAL STORAGE REGIST'RATI>ON
MAP NO. PARCEL NO.
ADDRESS OF TANK: /.�� �..'? fi ! l .*' (_ _ V I L L A G E
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) :
OWNER NAME: PHONE :.
INSTALLATION DATE: BY:
A
INSTALLER ADDRESS: -CERT.NO.
*TANK LOCATION:
(DG�QPt I ii�. TANK 1_OQAT Z ON W Z TH W COPCCT TO mU I LD I NO) �
CAPACITY �� t TYPE OF TANK , c L, AGE YRS. FUEL/CHEMICAL 1`
TESTING CERTIFICA�T/ION C ] PASS C ] FAIL DATE
LEAK DETECTION CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION C ] YES C NO DATE TO BE REMOVED
f-
FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE.
CONSERVATION [ ] CHECK IF N/A DATE Aw
BOARD OF HEALTH TAG NO. C ] DATE /
PLEASE PROVYDE A SKETCH SHOWING THE TANK, LOCATION ON THE BACK OF THIS CARD_.
Pioneer Chain Saws Full Servio9s
Sales&Service Authorized OMC Stem Drive
1/�4iea �V70��C C.r
pipe
""C�►nce'-s Cove Mai na
�tDow Clark - �
P.O. Box 338
Tel:428-5885 Prince Ave.
Marstons Mills, Mass.
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
.-- Mail To:
NAME OF BUSINESS:n /A UBoard of Health
MAILING ADDRESS: P--0 x �� of �R s M% A, Town of Barnstable
TELEPHONE NUMBER: — 7� P.O. Box 534
CONTACT PERSON: Hyannis, MA 02601
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totall' , at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous
characteristics and must be registered when stored ' squid
vial t. Please put a check beside each product that you store:
V Antifreeze (for gasoline or coolant systems) in cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
otor oil aste oil Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
,Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
phalt & roofing tar Leather dyes
Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
y cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy-Health Department/ Canary Copy-Business
r tp ,� f
a TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,'Repair
Q satisfactory 2.Printers
BOARD OF HEALTH y + 3.Auto Body Shops
O unsatisfactory- 4.Manufacturers
COMPANY NA I'i tJ,—v 15 111114rt �' (see"Orders") 5.Retail Stores
' / 6.Fuel Suppliers
ADDRESS 0 3,4'" �.� •^!�► , Class: / 7.Miscellaneous "
epy" " flee MX f p ' y'`' QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIAL Case lots Drums Above Tanks Underground Tanks
S
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
i
Gasoline,Jet Fuel(A) F
t " 1Diesel,Kerosene, #2=(B)
Heavy Oils:
d waste motor oil (C) z
new motor oil (C) fr
transmission/hydraulic
Synthetic Organi•c�s:
degreasers pmz, , ,
e . 111041
Miscellaneous:
�,to xlrrif .� (�f1f/2 t / 2—
X
f9uk4 561 v
DISPOSAL/RECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply � � '�
O Town Sewer Public
QrOn-site OPrivate
3. Indoor Floor Drains YES NO
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
t
4. Outdoor Surface drains:YES NO I/ ORDERS: '
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
5. Waste Transporter
Name of Hauler Destination Waste ProductLicensed?
`''t�"��'J�` �d�� r"�.,S"i"`
2. .
Person (s) Interviewed} Inspector Date
e "'
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF FIRM: urine Services & Electronics Inc. 3�
MAILING ADDRESS: P. 0. BOX 338 7
TELEPHONE NUMBER: MARSTONS MILLS, MASS. 02648
CONTACT PERSON:
Does your firm store any of the--toxic--or-hazardous-mateals-e-listed-
either for sale or for your own use, in quantities totalling, at any, time, more i
than 50 gallons liquid volume or 25 pounds dry weight? YES NO
This form must be returned to the Board of Health regardless of a YES or NO
answer. Use the enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a
site other than your mailing address :
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic j
or hazardous characteristics and must be registered when.stored in quantities
totalling more than 50 gallons liquid volume or 25 pounds dry weight. Please put !
as eck beside each product that you store:
1� Antifreeze (for gasline or coolant systems)w Refrigerants
Automatic transmission fluid Pesticides (insecticides, ;!
Engine and Radiator flushes herbicides,rodenticides)
Hydraulic fluid (including brake fluid) Photochemicals
Motor oils/waste oils Printing Ink ')
Gasoline, Jet fuel Wood preservatives
Diesel fuel, Kerosene, #2 heating oil (creosote)
Other petroleum products: grease,
lubricants Swimming Pool chlorine
Lye or caustic sodas
Degreasers for engines and metal Jewelry cleaners
Degreasers for driveways & garages Leather dyes
Battery acid (electrolyte) Fertilizers (if stored
Rustproofers outdoors)
Car wash detergents PCB' s
Car waxes and polishes Other chlorinated hydro-
Asphalt & roofing tar carbons, (inc.carbon
Paints, varnishes, stains, dyes
tetrachloride)
Paint and lacquer thinners Any other products with
Paint & Varnish removers, deglossers "Poison" labels (including
Paint brush cleaners chloroform, formaldehyde,
Floor & Furniture strippers hydrochloric acid, other
Metal polishes acids)
Laundry soil & stain removers
Other products not listed
(including bleach)
fl ii s� E I V E D which you feel may be
Spot removers & cleaning
z � toxic or hazardous please
(dry cleaners ) HEALTH DEPT.
st.:;
Other cleaning solvents TOWN OF BARNSTABLE li
Bug and tar removers
Household cleansers, oven cleaners
Drain cleaners
Toilet cleaners
Cesspool cleaners M AY 1 8 1981
Disinfectants
Road Salt (Halite)
_.�7_
TOWN OF BARNSTABLE
BOARD OF HEALTH
CO ROL OF TOXIC AND HAZARDOUS MATERIALS - INSPECTION SHEET
FIRM
ADDRESSr'. .
Major types of materials: 1) 4 2) 3)
4)
I. Description of material (s) use:
II. Storage (denote product by number listed above)
A. Containers
etal g_1 s pa pla is
cans,bottles,jars
drums,barrels
aboveground tanks ya
underground tanks 0/�/—
bags,boxes
open,loose,uncovered
inadequate labelling
B. Storage Facility "�/or-# Remarks/Recommendations
1. Indoor oe
a) separate, contained room
b) stored:in.general work area
i)' inadequate ventilation- _
ii):-floor drains L'
ii)° inadequate_ fire protection
2. Outdoor
a) uncovered, exposed to weather ; ..�
b) "pervious:sur-f�Lcel&-atths.basih
4 III. Disposal
A. Reclamation/Recycling unit
B. On-site disposal
1. Town. sewer
2. Regular septic—system '
3. Separate holding tank
C. Off-site disposal
1, hauled by own firm
2. hired hauler `
a) name of hauler
b) address or disposal site
] / 1
Person(s) Interviewed _ _ _ _ �_ _ _ _ _ _ _ _ InspectoS— ,
/
7;
l Date -- — — —