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HomeMy WebLinkAbout0030 RASCALLY RABBIT ROAD - Health 30 RASCALLY RABBIT Qv , M. MILLS A= 078 069.005 i r 9 u THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .-----1� ..............o F. j Appliratiun for Di-quiff al Workii Tunotrurtiun thrutit Application is hereby made for a Permit to Construct QC ) or Repair ( ) an Individual Sewage Disposal System at- ` .. _._ �� L._..�4y� 1 S....................•-•------- Location-Address or Lot No. ....--••-•-----------.................••-----•--.....-•-----------•----.....................•.... ..........--...................................................................................... Owner Address W ...---•---••-•-•••••............................................................................. Address Q Type of Building iEe 2.1.� Size Lot Q(P.JeOP...Sq. feet Dwelling—No. room .. .Expansion Attic ( ) Garbage Grinder (AA '4 Other—T e of Building o Showers — Cafeteria a' Other fixtures --------------------------- W Design Flow.. 5CFP-__1 .........gallons per person per day. Total daily flow........._............. ............gallons. GY Septic Tank—Liquid capacity_IQC'._gallons LengtlS."�...... Width.A. W. Diameter..`......... Depth-5 -- � Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..__......_........sq. ft. Seepage Pit No----------I......... Diameter-----ID--------- Depth below inlet................ Total leaching area...19. ....sq. ft. Z Other Distribution box (Y% Dosing-tank SO f Percolation Test Results Performed by ArX -- _. .E--_1- -................ Date..15?.{,1►�—;.-,z Test Pit No. 1. ......minutes per inch Depth of Test Pit______ _________ Depth to ground wa.S. �•t (z, Pit No. 2..4.2......minutes per inch Depth of Test Pit.......-`........ Depth to ground ate`r ---------------- Test .. : . ... . , i7ER....... O Description of Soil--�-•-.Q.....Z.... S.l?.13.....Zmi _ . ...���...*.?....... a> F w ......-••••-......--•••-•-• 4----.......6. .VO -- --------------------------------------------------------------------------•-----....fir s. ss 9 -------------------------------------------- ----------------------------- ---------------------------------------------------•-------------------------------------== _ . x s r........, �r U Nature of Repairs or Alterations—Answer when applicable................................................................... --� 4 � a M1 yam. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed b h oqAd of health. e— iy_ape, Signed 0.......... .............................. '! 7f ---------. -------------------------------- ----------------- Dare Application Approved By ... �----- ........................ ---------------------------------------------- ---/ Application Disapproved for the following reasons- -------- -----------------------�-----------------------...-.... ......... ..... .......................................................................... .................................. ................ . .. .............................. ....... ........................... �i Dare Permit No. ....J..-. :`".. �� - Issued `'` 1 ---------- FEB THE COMMONWEALTH OF MASSACHUSETTS _ BOAR—�D� OF HEALTH - ? ..Q..............OF...6"�.� ,1.. LI�� .�. :.---------..__......----...-_.._. Allp iratiun for Uiupuual Works Tomarnrfiun Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Location-Address or Lot No. .................................................................................................. ..........--...................................................................................... Owner Address W Address -�•� QType of Building r�af2 3�$ Size Lot�(?_�.�..............` Sq. feet v Dwelling—No. of - e room ___________ _ p ( ) g Expansion Attic Garbage Gander r Other—Type of Building ? _+`�_ c L--__._ N6./of`.g`ers&f's____________________________ Showers Cafeteria a' Other fixtures ____________________________ _ _ W Design Flow. a- 4%__!. ._____...gallons per person perday. Total daily flow..........4-�._Q.........................gallons. WSeptic Tank—Liquid capacity_�i._°._.gallons Lengtl8.._� ...._ Width_`���"Diameter"'"" _____ Depth_.�`.-'a.".� x Disposal Trench—No_____________________ Width.................... Total Length................. Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter-----`_C>-------- Depth below inlet--- s............. Total leaching area__1.9.:�t....sq. ft. Other Distribution box (Y�> Dosin z _,,,g tank ( ? '-' Percolation Test Results Performed by_ �. �' .• ................ Date__ ?__ aTest Pit No. L k�______minutes per inch Depth of Test Pit.......k ...______ Depth to ground der. .............. � fT Test Pit No. 2_4-L-______minutes per inch Depth of Test Pit.....i2i........ Depth to ground `e._....... Tc -q.-•-- .-� . ......................................................... __..__ .... ....._--..._. SULLIVAN. O Description of Soil....--�A ........................................................1 D U t J ..................................... d �� ',:� y ' - c- . _ ........... S -------------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable................................................................... -------------•-------••••---••-•--•---••••---•--------•••••-•-••--••-••---••--•----•--•••-•--•---•---•••------•-------•--•-•-----•-••-•-•--•-••-••----•-----•----•-•-•-••••-•-••••-••-•...-•••---_-•--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed b h o of health. 4 - 9-9d �y Signed - --------- -------------------------------------------------------- y---........ Application Approved B PP PP Y -- --..--... Application Disapproved for the following reasons- ...................................... -- -------------------- ---- - ------------ -------------------------------------- --------------------e---------------.-- Permit No. 90'' P z................................ Issued .... "'--��- �"`. 1� Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................................. OF .-- a�.�- �-- -.-`n`-'�-_----------------------- Gertifirate of Clumplianu THISU T CERT FY, ,T.h�at—the Individual Sewage Disposal System constructed (/� ) or Repaired ( ) by ..........-.- .... 11 -------------------------------- , g� ..nscallet �g at ------ J --- r ..��- ....... .t-` # �+ ..-�--.1�1- t�..a...�:--------------------------------_----- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................................ dated ----------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------------------------------------------------------------------- Inspector ..............................------------------ ------...-........ ---......-- -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.... '.'� -s ......................... .............� .OF.-- f .f*+ `�.-_�-t-N6..:....=�'_-.........._........._.. � FE ........ Rupuual Vorkg Tuntr ion eruti# Permission is hereby granted__._ f? /%s¢_4.7—in..................................................................................... to Constz ct ( . a) or Repair ( ) an�Individual Sev��aePDisgo-al System "' at No.---._ ?� ') ct �Cr``�...ate- . , 1•�!--! 1V F •1 l A Street M as shown on the application for Disposal Works Construction P No._p...4 Dated .._.... Board o �� ----- - ----------•-•----- • -_ --- Board of Health e' 4 DATE.......... ._... C`J--•-....---•---- FORM 1255 HOSES & WARREN. INC., PUBLISHERS -7 M fk? No.r LUT 'A(t IS' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 73 S 7K ................ .LEA.-..-.-.-.................J�Vpfirativu for Dispniial Works Toustrurfivit ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at* ..ED- ............................... L i -Addr s or Lot No. ... ....................................... .................................................................................................. Owner Address .................................................................................................. .................................................................................................. Installer Address Type of Building Size Lot..Aro '7 lz ----1-6. Q_Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic A01 Garbage Grinder 44 Other—Type of Building OFF-1c4s... g<n?---------------------------- Showers Cafeteria Otherfxtures ..................................................................................................... ................................................ Design Flow.115-./.toM..............gallons per person per day. Total daily flow......'T.k ........................gallons. _ _W .6 Septic Tank—Liquid capacity gallons Lengthltq:711".. Width_4.' .6. .... Diameter__--------- Depth_5.... .. D's osal T ench—No- -------------------- Width...._._........._... Total Length..3.G.......... Total leaching area..-....._----.- ---sq. f t. )ff' ' J?M i ni t.33Z.'!5'..... Total leaching area.. .I' ..sq. ft. Oesteppiagek No.....t-------------- &ia e ....a......... Dep 11 below 1 e ( 66 Dos in Other Distribution box I sin tank 40 Percolation Test Results Performed by%ArV-_TMC�A... .. ............ Test Pit No. 1..�4n��-----minutesperinch Depth of Test Pit...A.Zn......... Depth to ground Y10 N Depth of Test Pit. %Z...... Depth to groul W ..............Test Pit No. 2_,d_Z�...minutes per inch '1& 4 / I Ri ................................................................................r...................................... ....... . O Description of Soil--NA....... ---MAW. ..MF45.915 .......... ----------------- '5 ......... ......�4�............ ........-------------------------------------- ..... ..................... 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 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ee i ued by the bo olf h h. Signed ..... . ..... .. . I........ ..........................I-- ------------------------------ ------- ...... Application Approved Bya:' - --- ----------- ----$ ------- Date Application Disapproved for the following reasons: ................................................................................------------------------------------------------------ ..........................I.................................................................................................................................................................................... ....................................... Date Permit No. ------------------------------------ Issued --------------- --------- -7 . THE COMMONWEALTH OF MASSACHUSETTS BOAR-D OF HEALTH Appliration for 11iipusttl Works Tomitrnrtion famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemr�at ......3. �.a:: :�:{-: ...�* 4e?. _ ? �`. 3 �U a —5-............................... Location-Address or Lot No. ......................--.......................................................................... -•••...•••--...................................................................................... Owner Address W Installer Address �r �y UType of Building Size Lot____.._...2.7 r _L......_Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Ao Garbage Grinder ae Other—Type of Building 3 __. r p� ........................... Showers gc) — Cafeteria (k(b dOther fixtures ...--••••---•-•-••--------••-----•-••-••--•...•-••••-•....--••-•-•--•••--•••-•••••----------••-•••-•---•••-- Desi Flow. J�.. ..1 gallons per person per day. Total >1 ow..._...�.4 :......................gallons. W g P P ri ,, r r WSeptic Tank—Liquid capacity_-____......gallons Length ..`_,...._ Width.—............ Diameter............ Depth.5.."._ ?.. x D��.sp°,ts�aj:�&i1ch—No...._...._..`_�t.... Width.................... Total Length.._�-�__�?......... Total leaching area....................sq. ft. Seepage Y1t No_____ ______________ Diameter.___.r,�:�_........ De th below inlet_.��.:�._--- Total leaching area. ?._ .sq. ft. Z Other Distribution box ( Dosi tank (NO) Percolation Test Results� Performed b �'*� - _._ `' __. . Date_�V.f,\G-_� _ k9BI a Test Pit No. 1...4�Z ..... per inch Depth of Test Pit.... ......... Depth to ground wat (s, Test Pit No. 2---.__.�___...minutes per inch Depth of Test Pit.....1�.......... Depth to ground vo�tgx... ....... .... . ---_ .. ...... ...... .............. � ..... C,•IF O Description of Soil 1 t 1'� , 1 "�„ _its. �/- . c r -- . r" "' "'� w lx C cad, W ) )"� ` - �� �r�:.z5fis� U Nature of Repairs or Alterations—Answer when applicable..........................................:.....................:.i;: �!� :r—_�.-_��. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ee i sued by the board of health. sqtoSigned ..... ----- Application Approved By �- r�� ... .-. ...-..:.I_. ---------------------------------------------- �p Application Disapproved for the following reasons- ---------------- ----------- --------------- ---------------------------- ------- ---------------------------------------- ----------------- ----------------------- -- -- ------ --- ------. ------ -------- -- -- 47 - Date Permit No. .' .................................... Issued , --%�j�........ Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH bt.. ........... OF 75.KZJ J$� C� -------------------------- ge>rtifira a of (f empliattre THIS IS TO C TIF , That th Individual Sewage Disposal System constructed ( X,, ) or Repaired ( ) by -------------------------- '`f-t -- ...... ....... �� - - .. Ins Ile at ... �'� (,s.' �� �' '...--. -- ------ 2.��.. +'L,... ... '�....-:c..-...-.... --..--.. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... ^'..-pF "°� ..-. -- -------------- --------------------- Inspector -°_.. "�✓ .✓�"�... :- ------7- -- . ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No., �`"��... .. .............0 F...... ' �1 �� -? ......................... FEED. ... Dispsal Works Tnnotrudi.an anti# Permissionis hereby granted..................---------------------------.•-•--•••••••-••••...--•--•-••-------•-•---••---••--•-•---••-••••••••--•-••-•••.........•••••... to Construct (II(f or Repair ( ) an ndivldual Sewage Disposal System l Street as shown on the application for Disposal Works Construction Permit NC :nFf Da .._.._/--. \ --------------------------------- ---- --- 4A ......•....••........................................ Boar of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS l— , r JOSEPH A. 0ALUZ /willies Inspector 1 TELEPHONE: 775.1120 f EXT. 143 TOWN OF BARNSTABLE BUILDING INSPECTOR TOWN OFFICE 13UILDING HYANNIS, MASS. 02601 January 18 , 1990 s Triple R Trust P . O. Box 394 Marstons Mills , 111A 02648 Re : Site Plan Number: 53-89 , Rascally Rabbit Road Gentlemen : The above referenced site plan is disapproved due to its failure to comply with Section 3-3 . 5 (6) of the Zoning By-law. You may redesio.n your site plan to comely with these requirements and submit a new application for site plan review or you may seek a Variance from the requirements from the Zoning Board of Appeals . Should you have any questions , please feel free to call . Very truly yours , .To.sej;h E . 13carLell Si e Plan Review JEB/km cc Stephen A. Wilson , Baxter & Nye Gordon Clark , Northside Design All Site Plan Review staff r �G� i 3 P y d J S �o !) a i/ 1' 4 P (rp /fi1N PO �� Z 4T 4 --az-,a I - Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is Marstons Mills MA 02648 10/15/2014 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms �j on the computer, "I use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Neighborhood Waste Water t�l Company Name 350 Main St Company Address r W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2820 S15016 Telephone Number License Number i B. Certification 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 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/15/2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. LA I O �i I� t5ins•3113 Title 5 Offidal I Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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: System in good working condition. 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"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 ❑ ® 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 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ ® 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title ffi 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owners Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Cityrrown State Zip Code Date of Inspection 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 144SFx2.5= 357gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal'.use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: UnknownDate Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes 0 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 25 years per plan on file at BOH. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'3"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Cast iron exiting building connects to PVC. Line inspected with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 1'4"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 Dimensions: 1000Gal H-20 Sludge depth: 8" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 0" Distance from bottom of scum to bottom of outlet tee or baffle 0" How were dimensions determined? Sludge Judge/Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 Gal H-20 tank in good condition. PVC tees in place and clean. Both inlet and outlet covers are at grade. Tank at normal operating level. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M ,•�'°r 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Citylrown 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.): 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): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): H-20 DB-3 box with 1 line in and 1 line out in good condition. Box is clean and level with minimal signs of solids carryover. No signs of overloading or hydraulic failure.Cover is at grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6x4 ❑ leaching chambers number: ❑ 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.): 1-6x4 Leach pit was found dry at time of inspection. No staining or signs of hydraulic failure. Cover is at grade. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments vl�v 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +13'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: 12/19/1989 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: Test hole data per plan on file at BOH dated 12/19/1989. Test hole to 12'with no groundwater encountered. Bottom of leach pit at 8'. Also hand auger through bottom of leach pit to 156"with no groundwater encountered. Minimum of 5' separation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,•' 30 Rascally Rabbit Rd. Property Address Robert Engleman Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 10/15/2014 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE r1 ! LOCATION '�d SEWAGE# VILLAG S ASSESSOR'S MAP&LOT INSTAU"VS NAME&PHONE NO. n fba4l) Lf 9 b-,S SEPTIC TANK CAPACITY LEACHING FACUM:(type) (tee) NO.OF BEDROOMS I BUILDER OR OWNER PERMITDATE: COMPLIANCE DAZE: 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 hie facility) Feet Furnished by _ 411�,w (771tra 04!S5e0 Y l fib" 13'3" G 2 25 i$y i 3 3" p3'fir"' ID VE http://www.town.barnstable.ma.us/Assessing/HMdisplay.asp?mappar=078069003&seq=1 10/9/2014 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r s• TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION DJ�> 06 cl 003 Property Address: 30 RASCALLY RABBIT RD MARSTONS MILLS Owners Name: LARSON Owner's Address: Date of Inspection:8/4/06 Name of Inspector:.(please print) Douglas A.Brown Company Name: Douglas A.Brown Septic Inspections Mailing Address:P.0 Box 145 > Centerville,MA 02632 Telephone Number: 508-420-4534 - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that&information reported below is true,accurate and complete as of the time of the inspection.The inspection was per`fdrmed 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 8/4/06 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving, authority. Notes and Comments SYSTEM PASSES PIT ABOUT 1/2 FULL AT THIS TIME ****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. Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/31/2000 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFICATION (continued) Property Address: 30 RASCALLY RABBIT RD MARSTONS MILLS Owner's Name: LARSON Owner's Address: Date of Inspection: 8/4/06 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 winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: one or more system components as described in the"Conditional Pase' 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 following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health, *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced 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 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 RASCALLY RABBIT RD MARSTONS MILLS Owner's Name: LARSON Owner's Address: Date of Inspection: 8/4/06 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 I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 RASCALLY RABBIT RD MARSTONS MILLS Owner's Name: LARSON Owner's Address: Date of Inspection:8/4/06 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 1/2 day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped — X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. R Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure, E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or no to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 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''m 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 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 30 RASCALLY RABBIT RD MARSTONS MILLS Owner: LARSON Date of Inspection: 8/4/06 Check if the followinghave been done.You must indicate"yes"or"no" as to each of the following: Y g 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 ? _ Were all system components,excluding,the SAS,located on site? X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3 ))(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 30 RASCALLY RABBIT RD MARSTONS MILLS Owner's Name: LARSON Owner's Address: Date of Inspection. 8/4/06 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 1 DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: Does residence have a garbage grinder(yes or no): NA Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NA Seasonal use: (yes or no):_ Water meter readings,if available(last 2 years usage(gpd)): NA Sump pump(yes or no): NO Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): _ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): _ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) - Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site (yes or no)? NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 RASCALLY RABBIT RD MARSTONS MILLS Owner's Name: LARSON Owner's Address: Date of Inspection: 8/4/06 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: X concrete_metal_fiberglass _polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 1000 gal Sludge depth: 6° Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: TRACE Distance from top of scum to top of outlet tee or baffle: 0 Distance from bottom of scum to bottom of outlet tee or baffle: 0 How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) METAL COVERS ALL TO GRADE TANK LOOKS SOUND AT THIS TIME GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 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: 30 RASCALLY RABBIT RD MARSTONS MILLS Owner's Name: LARSON Owner's Address: Date of Inspection: 8/4/06 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): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any ev,'dence of leakage into or out of box,etc.): LeO r1 �� L p S� Cdoer Jvo G V fcv\� PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): � j i Page 9 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 RASCALLY RABBIT RD MARSTONS MILLS Owner's Name: LARSON Owner's Address: Date of Inspection: 8/4/06 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: leaching chambers,number: 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.): PIT IS ABOUT HALF FULL AT THIS TWE NO STAIN LINE,COVER TO GRADE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 RASCALLY RABBIT RD MARSTONS MILLS Owner's Name: LARSON Owner's Address: Date of Inspection: 8/4/06 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. 13' 311 Fro N F L Z 3 i Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 RASCALLY RABBIT RD MARSTONS MILLS Owner's Name: LARSON Owner's Address: Date of Inspection: 8/4/06 SITE EXAM Slope: Surface water: Check cellar: Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: 78 144" (No l)a;k�� -45,o „ tvo.[r.� 39'y A: 144 39,9 I4� E5LGN DATA: 11$4Z X... 75�jp4 /4000 s F2,0 G pi Daily Flow E .US,E 2000 Gallon 72An1q, I C4chl.4 �roGi'/iff. A/c,wd,11v.:e.S 'd/2 .5,dcwa//s 2(36+ a)(3,Z5)(Z,S gpd/.5F) =� 7/5 Cha9i,I�-sr-� =Z60 S74 sF goo y�o' oaslrvc>7o� O�rcG ir! ?n`��/ooi- o� .S/��a1c L�ai•iI . ZL'3e:3o� Y 75!1Pd /I000 sr- = 50 %rho-��c. ►a,�k : USE loon Gelloh �an{t /cocl, ,o,t cwle'jloac t . S•eCc we// //SSF x Z.�r„/�s� - Zgg C��o„/ 7`I Gpd �►/y4SF 357 Gp�' R T..�CJ/ED l/LE_-..7�e�lac Syr l`ciras 60�s_ B latp.... Slura pie---I§afi7-.. ir�.:.aE_.�'cw►asoa�.r7..----•---... . _ . .__..... ---- .._.�L.O..- --- .._. ... : 5L.C3"--- ._...:... ._- 4 9ccE`'--AkE--Dis f:_1dd.X:-(t3Tly`�---- --::__."�.::_" 4, fy......_ _ �4,5__.. ...— C.w!f iL Exlsr�►..rc,� V' .1 ' "IT" r�s� �5 T ccwG�,,, L IL vu apo-e— 'T'b 69 Z'b M e r No..7...P'r' Z- &9A ) 3 A $ ; �ls L, FsS.........................2? THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I.. "AJ.Q..............oF. 5- AEM.S.-MBLE.................................. AVVIftativIt for BI,51109al lVorks Tdlpt. trurtivit Vprnttt r u ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3p /�u S ck /l7 l�kby,fRo� A114/-s •,s /J,r,l/ Owner: wLj I/ir���r Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' U e DEPTH TO GROUNDWATER Depth to groundwater: >1a feet method of determination or approximation: 9,i ted o�� (revised 8/15/95) 9 s� ti. s t 00 , Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of [31GVLSNMjo"Ma. Environmental Protection �" 166T t� �`dW William F.Weld Trudymcw t;oxe ®�/\ �/��d - 9eentuy,EOEA David S.Struhs commwton.r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO ����8��® PART A CERTIFICATION Property Address: 30 A0asc¢li R., L t 9,f /our y Via„s /��� Address of Owner: MAR ? 4 1997 Date of Inspection: 3_a!-g� (If different) FIEALTF;Q`pT Name of Inspector: -TO4 ,, q Aa 1 t TOWN OF CAF�ASTABLE Company Name, Address and Telephone Number: r04h /74 lr ?51,rF41e s? ll1f- • /Y/ars�vNs N�1/S A'J�,, Sa S-'�� •9 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Sig re: Date: 3—,Z/_ 97 aCif'-�" The System Iri`ector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: .Check A, B, C, or D: Al SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 61 SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Steel • Boston,Massachusetts 02108 a FAX(617)SM1049 a Telephone(617)292-UW PrMt"d.RWYCW P.W c r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:' 30 /?4 tY 17 /�bh��f /U Owner: i Rob lei 114 Date of Inspection: r. 3 2/= 9`7 ; BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage;bacRrs or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to roken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced kstruction is removed distH�utiion box is levelled qr replaced it pumping more tha our times-'a year due to broken or obstructed pipe(s). The system will pass _ The system required p p g Y inspection if(with approval of the Board o ealth): broken pipe(s) are e�aced obstruction is'remove Cl FURTHER EVALUATION IS REQUIRED BY/THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in o -er to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTE � NOT FUNCTIONING IN A MANNER WHICH WILL PROTECTIHE PUBLIC HEALTH AND SAFETY AND THE ENVIR9? ME4T.- Cesspool or privy *,within 50 feet of a surface water . Cesspool or privy is Within 50 feet of a bordering vegetated wetlarid or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT,.-,!HE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil abso[euo /system and is within 100 feet to a wiface water supply or tributary to a surface water supply. _ The system has a septic tank and soil abs ption•,system and is within a Zone I of a public water supply well. The system has a septic tank and soil a�orption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil) absorption system\and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water anelysis 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• �. DJ SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15A03. The basis for this determination is identified below.. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of�ewage into facility or system component due to an overloaded or dogged 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. (revised 6/15/95) 2 � s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ff CERTIFICATION (continued) Property Address: o Owner: 1-30lj (/I/lu Date of Inspection: 3 2�' S 7 DJ SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. — Liquid depth in ces ool is less than 6" below invert or available volume is less than 1/2 day flow. >a Required pumping more n 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped , Any portion of the Soil Absorpti System, cesspool or privy is below the.,liigh groundwater elevation. — Any portion of a cesspool or privy is�within 100 feet.of a surface water supply or tributary to a surface water supply. — Any portion of a cesspool or privy is withiQ a Zone I of.a public well. — Any portion of a cesspool or privy is within 50jeet of a pritiate water supply well. Any portion of a cesspool or privy is less than 100�ee,t`but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has bed�analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammon�t nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems iryaddition to the criteria a ve: The design flow of system is 10,000 gpd/rgr'eater (Large System) and the s stem is a significant threat to public health and safety and the environment because one or /re of the following conditions exist: th e system is within 400 het of a surface drinking water supply — 8 PP Y the system is within 00 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) The owner or operator of aqy such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMIj/5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Owner: Ovk V/,//ei Date of Inspection: Check if the (following have been done: ✓ Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. Zhe system does not receive non-sanitary or industrial waste flow _.V/The site was inspected for signs of breakout. ZII system components, excluding the Soil Absorption System, have been located on the site. Zhe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. V The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility owner (dnd occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal Svstem. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: '30 fQk S �4��� �•r ?i,�,'7 ��� ��vs�OHa /y�1�S Owner: /-?o b V/'& Date of Inspection: 3 FLOW CONDITIONS , RESIDENTIAL: Design flow: ¢allons Number of bedrooms: Number of current residents:_ Garbage grinder (yes or no):_ Laundry connected to system (yes or no):_ Seasonal use (yes or no):_ Water meter readings, if available: Last.date of occupancy: COMM ERCIAUINDUSTRIAL: Type of establishment: Design flow:.3T7 gallons/day Grease trap present: (yes or no) /VO Industrial Waste Holding Tank present: (yes or no)�0 Non-sanitary waste discharged to the Title 5 system: (yes or no) lye Water meter readings, if available: %yY6 004 4/s J y YS — /Poll y44 Last date of occupancy: 4* olz p" OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: _ 0"P System pumped as part of inspection: (yes or no)_O If yes, volume pumped: gallons Reason for pumping: TY7SYSTEM - 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: ear Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3d l�a s,C11h Rubh, R�� �tv3 ��t N'/4 Owner: Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: ' Material of construction: Zoncrete _metal _FRP_other(explain) sT /Owl,Ad N�0 7ti k — C„s7 rson ""At lee )lee Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ?a k u,ohe-c` jr h 't P We k G TRAP:_ (locate o to plan) Depth below grade: Material of construction: _ crete _metal _FRP_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outet>ble- I Distance from bottom of From to bottom : Comments: `— (recommendation for pumping. c ion of inlet and outlet tees or baffles, depth of ligtiid-lev�l,in relation to outlet invert, structural integrity, evidence of leaka tc.) (revised $11s/9s) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 �as cw��� �a �� R11 / Owner: Date of Inspection: dud L1,�14 7 IGHT OR HOLDING TANK:_ (lo on site plan) Depth below e: Material of constru n: _concrete_metal _FRP_other(explain) Dimensions: Capacity:_ ftee gallons Design flow: gallons/day Alarm level: Comments: (condition of indition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) ad ' • . a� h� . a' ljv t6 O P Clit P CHAMBER:_ (locate o Ian) Pumps in working order.(yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenan (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 'j!9 gee J ca l/f-/ /;ti�✓�, ley Owner: Re I,- Ui//at Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) ° If not determined to be present, explain: --------------- Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, siig`ns of hydraulic failure, level of pyond"ing, condition of vegetation,etc�.) Al SPOOLS: _ (Iota n site plan) Number and con n: Depth-top of liquid to inlet m Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as pa 4 spection) Comments: o 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 gfl y raulic failure, level of poriding, ndi' of vegetation, etc.) (revised 8/15/95) 8 l / ti Commonweafth of Massachusetts B Executive Office of Environmental Affairs Department of y M f Environmental Protection qY o William F.Weld °k�ATq 199� G"Mor ~ Trudy Coxe SeeMary,ECFA David 8. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Z t PART A CERTIFICATION Property Address: 30 R6, UG t RA# arS�a.s /VOI Address of Owner: Date of Inspection: ;7-21—9 (If different) Name of Inspector: V4ti , H 11 4t 1 ry Company Name, Address and Telephone Number: J-04h Aq /40 1.4,eA4pe 5eI,vrcr /Ylursto-1 114"l/s N., S-9 5'9 S 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Sign re: � Date: The System In?ectortshall submit a copy of this inspection report to the Approving Authority within.thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: .Check A, B, C, or D: A] SYSTEM PASSES: . I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) On•Wlnt•r Str••t • Boston,Masaachu"M 02106 • PAX(617)SW1049 • T•1•0hon•(617)292-lf300 Printed an Retitled Psw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 /?4 6crr Owner: Date of�lnspection: a'/_ �r. B) SYSTEM CONDITIONALLY PASSES,(continued) =� 7 Sewal;6 ac' or breakout or high static water level observed in the distribution box is due to broken or obstructed `�-�pipe(s) or due to roken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): �.' broken pipe(s) are replaced obstruction is removed l disc' u�tion box is levelled or/replaced n more that our times'a year due to broken or obstructed pipe(s). The system will pass _ The system required pumping Y inspection if(with approval of the Board o earth): broken pipe(s)are eplaced obstruction is,removed\ C) FURTHER EVALUATION IS REQUIRED.BY T14i BOARD OF HEALTH: Conditions exist which require furt eh r evaluation by the Board of Health in or er to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTE, t5 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECTATHE PUBLIC HEALTH AND SAFETY AND THE ENVIRQNME ,i Cesspool or privy s�within 50 feet of a surface water % Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. r IF APPROPRIATE) DETERMINES THAT 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLI.CfWATER SUPPLIER, . THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: f The Svstem has a septic tank and soil absotpuon/stem and is within WO feet to a wlface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absoFption,system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil a orption system and is within 50 feet of a private water supply well. te The system has a septic tank and soils bsorption sysr hand is less than 100 feet but 50 feet or more from a private water supply well, unless a well water an-lysis 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• D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contaciedd to determine what will be necessary to correct the failure. \ _ Backup of sewage into facility or system component due to an overloaded orb dogged 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. (revised 8/15/95) 2 c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �30 /?4 S c* l Owner: /-30% Date of Inspection: 3-��- �7 D) SYSTEM FAILS (continue Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in ces ool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more han 4 times in the last year NOT due to clogged or obst/rutted pipe(s). Number of times pumped \� Any portion of the Soil Absorpuo�System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy i\within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is wit in a Zone I 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 \100eet/but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has bee analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, a on nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems i addition to the criteria ab ve: The design flow of system is 10,000 gpd r greater (Large System) and the s stem is a significant threat to public health and safety and the environment because one or re of the following conditions exist: the system is within 400 het of a surface drinking water supply the system is within 00 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 s4ply well) The owner or operator of an4ch system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR/5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 0/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �scu 117 30 /� Owner: 130k 11>11a Date of Inspection: Check if the (following have been done: d Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates ' during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. Zs built plans have been obtained and examined. Note if they are not available with N/A. -ZThe facility or dwelling was inspected for signs of sewage back-up. _VlThe system does not receive non-sanitary or industrial waste flow __VlThe site was inspected for signs of breakout. ZII system components, excluding the Soil Absorption System, have been located on the site. ✓The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. V The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. / The iacility owner (dnd occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal Svstem. (revised 6115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: '3O fQ•a S ck�l� �c, aa;d�rj Rj� Owner: /3v b Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: Rallons Number of bedrooms: Number of current residents:_ Garbage grinder (yes or no):_ Laundry connected to system (yes or no):_ Seasonal use (yes or no):_ Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL• Type of establishment•. Design flow:,35 7 gallons/day Grease trap present: (yes or no) /i/0 Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no)AV Water meter readings, if available: %9 yG — 0V4 Q/.f J`/`/S-- /'Ppa Last date of occupancy: 41a OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ,y0-I p System pumped as part of iinspection: (yes or no)_O If yes, volume pumped: allons Reason for pumping: TYPE OBE 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: sv 7 4e4rs Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 `�u sCa��� �u�j{�, /Qcr', Owner: 01910 Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: � Material of construction: t�concrete _metal _FRP —other(explain) &-"'ST ��O�ced✓/ �070 TO, - C.r 5' /don 1,t lee - ?yC D f�f tee Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: r2l Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) %a k 7n GF i' 6"W1 e"'X-X�a't G,WA,g TRAP:_ (locate o it, plan) Depth below grade: Material of construction: _ crete _metal _FRP—other(explain) Dimensions: Scum thickness: Distance from top of 7ett tee or baffle: Distance from bottomof ouflet tee affle: Comments: (recommendation for of inlet and outlet tees or baffles, depth of liquid-level in relation to outlet invert, structural integrity, evidence of � I 6 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMp INFORMATION (continued) Property Address: Owner: Date of Inspection: 97 IGHT OR HOLDING TANK:_ (lo on site plan) Depth below g e: Material of co n: _concrete_metal _FRP—other(explain) Dimensions: Capacity: Ral Ions Design flow: Rallons/day K Alarm level: Comments: (condition of inlet tee ndition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: o Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) .00'e O��'��p7�� �vY �Ave-'f 5 70 P P CHAMBER:_ (locate o Ian) Pumps in working order:(yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenance ,set . (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 0 ��s c�Jif�/ /1014 b)4/ Owner: R I bli//ac Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) /Vie s S�EZ—� �i:�y►�P or- bjr- - S SPOOLS: _ (loca can site plan) Number and con ratter Depth-top of liquid to inlet m Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part spection) Comments: 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 g raulic failure, level of ponding, nd+ti n of vegetation, etc.) (revised 8/15/95) 8 r ' u SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3O A s co l� lQa�bi float j NO Owner: 001j 7 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ffio�uy� Nd. � as" 13 a L DEPTH TO GROUNDWATER Depth to groundwater: >/'a feet method of determination or approximation: 9,?Jed C, Per k -- tP51' A Le 4-r,,-,7 ov.`5�u4 (revised 8/15/95) 9 i __ I 7 a ti 10 •• ^ / y •y.? a ii� �• /y�'0 fir'Jli P� oo, /pY , ^J Po e • / v A/ n • 6 � � 5 ti 6etr � y �.0\ yi ,, /�. •• 59.0 ••,••• •� Sg I I ..r`jd i;,P•.'n�'!i(!-':J aL!J. 'j:'' ,�C• 79• ••••••••• ••• •� ^ I , � � [q O 1;�'r`r.�:(r...%'g`':�W�� !/��r• i�ft'•�"'a�µ �� � \ •, .`+, y 4 l_,(_-;.•. :�. ,� � �.�: r ',: .1J,fi..Fri,,.d:�,'y ti•!' ,, \ y I G, 1„ L�(..,7r, N«�✓ ' .r+.. d.., it to .IC,fiirk,% .1j". •.1u LEGEND \ , QW.G. '.}C E1CCA•;, /fir//474 Nyd�..rt S C A L t - V '= 20 , r•A,- /VOTE : Loe.afsan of (Jnc�ti�rt�v.rc/ Uri/uses il�e Aa0/uigJgJ»..�E, cn •�' �0. ..•d• ,st 6 , •,.r ;_..•�: R •-� �7 � 7,l O 2 NO S P or 'f0 C .•���R L%IL t1n�t.CMiew• :: "SA-WG�i ,- e,- / S Jt"E CO an /sic Coro/rbcf"o A9usf N ! "D G A i.. � fy ' pofe.(: Gon�our (I-000 -_4ZZ-4844) aNct +4u Cc FcrviIle- Ostrruillr 78'1 54 S '3/i-4tijr� � I o 144° q9.o 144" 39.4 1A4 E5IGN DATA: x.. 75!a,,cf /l:000 sr- = j.I z,0 G pd Da*rly Fiow 4 c , c. Tank 'TIZ.oxI4 0 _ �0(o8 Gallo-is : ........ .... i ..Us.E Z000 Gallon Tanl-,, C4cAiN� rroci'/ify � /C/owc.���se.� ��Z�.SCronC �, , .5 c(cwa//s 2(34+ a)(3.25 (Z.5 Bpd/SF) =1 715 y�cl -36 x >?3 ) C/.o 9�/.sr-� =2 0 6 S7.4 SF /00 3 9�a✓ o�Slrucfro� O�cG .q ?n.v'�/ooi- o� s/a�n�e ae�H ZL')e-30 Y 75:ipcA /(000 Sr' = SO :r10-��c la.,k VSE . �000 G:11or �ank e000,4e//0.j level, wit tole jload r S.dc wa// //SSA x.Z.S��,.,//sue - l88 Goo.,/ • /30 79s0-)e 40 d/SF = 79 Gpd 5c vl5r� S�.rlc.s>s (.ZN) MeF.-tie f��f�„ A trtiYl�d+ � �n�sr�Nc�; •L��c �'�'hc'" ,��3� �S�T ccw��„, • S U S tt -R� F t r.�►R'�*�,.. be 2 a45 r• i Lt '14A.c.c.oM10Aw,KA. LC v j t'Tli 'C�'�:.... ;''�'>�tY'� TA £3� i►�!�'T'►'�!.�.Et> fti 5 ;°Er`�l��...�� .r� � �jOr►�O_`D e�F }�'!°�+4t�'�t.� irro..ln..Q'.r' Z_ F$s..../�'l` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L ►,�..............o F'>rti r<.58. ................................. , Vpfirativit for PI_qjiv3 i arks C VIVa, trurthm 11nnttt TOWN O/F/ B/ARNSTABLE O ,1( qQ_ LOCATION SEWAGE # VILLAGE i '`'� - %�i ��� ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO., olt� SEPTIC TANK CAPACITY 1 �.;; - LEACHING FACILITY:(type) ?� (size) 00 NO. OF BEDROOMS PRIVATE WELL OR��PUBLIC-,WATER BUILDER 04�&NER - F DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No - i \ r t S j ,- TOWN OF BARNSTABLE LOCATION SE II SEWAGE # VMLAGE l S5 ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. 9 E9S SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER iv�� V ►��� PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of 1 achin facility) Feet Furnished by '7►G 13'3,. 2� Z 2 3�. 8�� O 3'�g,, i�,i �.b►�. . �(�'. D (� 9� r �� �� r Date: 11 / t 8 /F 5 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: s,�� SAS BUSINESS LOCATION: 3Q INVENTORY MAILING ADDRESS: 16 Y,%A1,k5 07,5-3 TOTAL AMOUNT: '"` TELEPHONE NUMBER: 6A CONTACT PERSON: G .•, EMERGENCY CONTACT TELEPH NE NUMBER: MSDS ON SITE? i TYPE OF BUSINESS: 7mL_ INFORMATION / RECOMMENDATIONS: Fire District: M Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wo od preservatives (creosote) Caulk/Grout 3Z-0 OLSwimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash es detergents Leather dyes Y 'I Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list):- Metal polishes MAr% 7)y11.sGq�o Qa nlll: S i o�2[A Laundry soil &stain removers o� 5 of ARV (including bleach) c-Gf sr"_ r7z rn L)tw p %tA SAO Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant' gnature Staff's Initi J :1. . YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME In town (which you. must clo by M.G.L.-it does not give you permission to operate.) You must,first obtain the necessary signatures on this form at 200 Main St:, Hyannis, Take the completed form to the Town Clerk's Office-,'Jst R., 367 Main St., Hyannis, MA 02601 (Town'Fiall) and get the Business Certificate that is ' required by law. ; � DATE: 11 2`� I.•5 Fill in'please: ••, . ffil-I W,im.°vni•L'}{Jf I•'f6GuA., '� ({,'jYC O .' APPLICANT'S YOUR NAME%S: E A2 p •6�iij���'�'�S �'" BUSINESS YOUR HOME ADDRESS: See-868-5 200 TELEPHONE # Home Telephone Number �y�-Gc`iB►�Gl S• r ry , .O A o �. S�f 'OF C ORP R ME 'I N T N� ... - 'i`� 4`1•t tr hit �•.:. •CE`BUSINES5�5t:1i +,t'�' •:r. .,. S ES r, 'IVAIVI E`OF�NEW •,'•- -1 '4• !: V i 7r% K,:j r:O.= ;:YE S: - OCG P -, •.,, !; :::, -,:;. �:�... .'P'.Pi4RCE .NLIIVIB�R s �YZ �`(AS�.@... .�.•.9).E_�.a.' .- cI7pRE5HOM S:.OL�5INESS's� When starting a new business there are several things you must do in order to be in compliance with the rules and regulatlons of the Town'of Barnstable. This form Is intended to assist you in obtaining the information you.may need. You MUST GO TO 200 Main St. -('corner of Yarmouth Rd. & Main Street) to-make sure you have the appropriate permits and licenses required to legally operate your business in this town. ' :.;rM �i 1. BUILDING COMMIS510NER'S FFICE This lndivldual has bee rmed of y permit requirements that pertain to this type of business: . } J Authorized Signattre* COMMENTS: 2. BOARD OF HEALTH mustCOMPLY'1�VITH ALL:: This Individual has been Informed of the, ;er re uir m nts that pertain to this type of business. HAZARDOUS MATERIALS REGULAT�Q 1S. ; Authorized Signature** COMMENTS: ---------------- S. CONSUMER AFFAIRS (LICENSING AUTHORITY] This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: ; . . . 8/1/2016 30 Rascally Rabbit Rd-Google Maps oogle Maps 30 Rascally Rabbit Rd z.� - ZIP. r" - a ` stun Mills at5it Li at r , bemelssr qfy shod, " .. - 55 ',e ool https://www.g oog le.corn(maps/place/30+Rascally+Rabbit+Rd,+Barnstable,+MA+02648/@41.6556231,-70.413498,16z/data=!4m5!3m4!1 s0�9fb32c3l a75ef85:0)Q6e6814f5fff726d!8m2!3d4l.655579!4d-70.411202 1/2 Number Fee 1249 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that By the Seasons Pool Service 30 Rascally Rabbit Road, Marstons Mills, MA Is Hereby Granted a License For: Storing or Handling 111 -499 gallons of Hazardous Materials. ---------------- ------------------------ --------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2020 unless sooner suspended or revoked. -------------- -- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI, M.D. 07/01/2019 JUNICHI SAWAYANAGI THOMAS A. MCKEAN, R.S.,CHO Director of Public Health I w. I Town of Barnstable Inspectional Services #r. - RNSTABLE u,3 Baru=° Ma 15;e Public Health Division =�9-zo14 • D Thomas McKean, Director C Arf1639.39,E a 200 Main Street, Hyannis, MA 02601 Q Office: 508-862-4644 Fax: 508-790A304 �kh APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE c. HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st-JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ `0.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ,9V��1 Lt El CATEGORY 3 PERMIT 500 or more Gallons: $150.00 *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 0 �S' l_ !ko 3 2. IS THIS A PERMIT RENEWAL?JZYES_NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? Y`ESSf NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: 5, f,#5 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: b1z sec Son S,Z �c-Gov Co 10. SOLEOWNER: V YES_NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: _ CORPORATION NAME v —flu— S e-ctSc,�.S L h c- PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT ATE �p 1b% Q\Application Forms\Haz Mat App Revised 09-10-18. _ _ I 7 (oq`°Ft ropti Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • sa MASS' ASS 200 Main Street• Hyannis, MA 02601 i639 M TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT CFO Ay a Business Name: Date: V/ Location/Mailing Ad ess: 1 Contact Name/Phone: Q g� — & 0 n Inventory Total Amount: ���� SDS: License#: Tier II : M0 Labeling: Spill Plan: _ Oil/Water Separator: Ad Floor Drains: IVd Emergency Numbers: ° Storage Areas/Tanks: fin Emergency/Containment Equipment: ` Crib , Waste Generator ID: Waste Product: At Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) indshield wash Motor oils miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar —'Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint,&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: n6 Inspector: . Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Number Fee 1249 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that By the Seasons Pool Service .-------------------------------------------------------------------------------------------------------------------------------- 30 Rascally Rabbit Road, Marstons Mills,MA .------------------------------------------------------------------------------------------------------------------------------------------------------------------•.... Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- Restrictions: .------------------------------------------------------------------------------------------------------------------------------------------------------------------. This license is granted in conformity with the Statutes and ordinances relating there to, and expires 06/30/2021 unless sooner suspended or revoked. ---------------------------------------- JOHN NORMAN DONALD A.GUADAGNOLI,M.D. 07/01/2020 PAUL J.CANNIFF,D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health 4 Town of Barnstable y Inspectional Services BARNSTABI,E QF F 4:Ta -CEMEM U_C=n-•Y4R'MS Public Health DivisionxN 5•�SEkYL•t•?58?Vt5A8!E 1639-3014 53yg 1 B sAM Thomas McKean, Director ' p s 200 Main Street, Hyannis,MA 02601 0 Office: 508-862-4644 Fax: 508-790-6304 J, APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS5 IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st-JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 .CATE,C-ORY-2.PERMIT 111 —499 Gallons: $125.00 �V er c0iCi�11L CATEGORY 3 PERMIT 500 or more Gallons. $150.00 ❑ `22 *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? l/ YES_NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: t C!won i C fro 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: 16 R.6 + 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: & k--, ca ,5 ®i�37 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: t�a- Ys� Ste•Sc��^S , ��� 10. SOLEOWNER: YES 1/NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: ,I 9 SIGNATURE OF APPLICAN DATE Q:Wpplication Fonns\Haz Mat Appli Draft Jan2019.doc `°Ft►�ro,,ti • Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 BABNpSBBL& 200 Main Street• Hyannis, MA 02601 prfO039. MP+ TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: _ `� Z, S �S Date: Locatibn/Mailing Address: 0 b� rya Contact Name/Phone: S Inventory Total Amount: I�I SDS: License#: Tier II : 1P0 Labeling: Spill Plan: Oil/WaterSeparator:_ Floor Drains: J OC�-- Emergency Numbers: Storage Areas/Tanks: v ww rA I Ir Emergency/Containment Equipment: i It C' d S w IM&Y, Waste Generator ID: NIA Waste Product: �✓fl Date&Amount of Last Shipment/Frequengy: A f l^ Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil D'{qirofectants Miscellaneous petroleum products: salts koL65 grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar V Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda. Lacquer thinners J Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons fn`CA0rv7oo16 Laundry soil &stain removers (including carbon tetrachloride) f+y�PlC�lm4p (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde,, C hydrochloric acid, other acids) Caksbm A(4r'�Jp— so�U�b)Carbon uV,.-g5oto 7sl� VIOLATIONS: ORDERS: INFORMATION RECOMMENDATIONS: ` ` Inspector: Facility Representativ _ WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS °F�►+E toy Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • BASMASS. 200 Main Street• Hyannis, MA 02601 �iOrFOMP TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: Q u- 5e.0"'.0v`s ?oo� cv, Date: g b Location/Mailing Ad ress: 30 e4,l 10b M-Af. 4i - I(o Ki aft s •S,45,e� Contact Name/Phone: _4 a<V n I-e-Tro -508 - 42o-.SZoO InventoryTotal Amount: ^' !�d &`-y MSDS: `e6` v h4e--o 5.V2 License#.� Tier II : a Labeling: r1'vo Spill Plan: 6K_+0 Oil/WaterSeparator: NIA Floor Drains: M 0 Emergency Numbers: ooSk Storage Areasl Tan ks: a a,( kZ `5C P,Ca,`Yv-j0<v KA, Io , Emergency/Containment ui ment: 1 0,11 k i g 4 VF-6AV&-' ti Waste Generator ID: IWaste Product: Date&Amount of Last Ship ent/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. JAntifreeze 'A�'o'� � ��� a"��� Dry Automatic transmission fluid y"Q4��g Other l cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries I Photochemicals(Fixers) � Rustproofers Photochemicals(Developer) ,L Car wash detergents Printing ink �os.�� Car waxes and polishes Wood preservatives(creosote) �o Asphalt&roofing tar Swimming pool chlorine 321-4, Paints, varnishes, stains, dyes Lye or caustic soda \q- Lacquer thinners Miscellaneous Combustible '37' �b �k\14`60 Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: a `�- r-� \\a,��w�r5 `JS � S 5°1Lowt.C�ILI GriVGLk l�.`V\e, • Inspector: I v-P lkvwA-*�S �,'lityRepresentative: eel YYLWHITE`COP�-HEALTH DEPARTMENT/CANARY COPY- BUSINESS Town of Barnstable EVE Regulatory Services Richard V. Scali,Director ` MAS& Public Health Division Thomas McKean,Director ; 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 El�; Application Fee: $100.0.0 r�'1 ASSESSORS MAP AND PARCEL NO. 078-O(o'? - ATE I 1 S APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT G( C11 [Awl )I cM NAME OF ESTABLISHMENT c)�v �� �cSo►.lS ADDRESS OF ESTABLISHMENT TELEPHONE NUMBER 8 69 -522 2 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. STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK —A-��4 .SI OF APPLICANT RESTRICTIONS: HOME ADDRESS . Ib ki pms (,t)n,-5I t - ',-A—I ftLA ;;; HOME TELEPHONE# `5-08 P 6 H J�-Zoc7 C:\cache\Temporary Intemet Fi1es\0LKD3\HAZAPP RevN I5.DOC YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you, must do by M.G.L.-it does not give you permission to operate.) You m1ust•first obtain the necessary signatures on this form'at 200 Main St., Hyannis, Take the completed form to the Town Clerk's Office'.1'st FI., 367 Main St., Hyannis, MA 02601 (Town'Hall) and get'the Business Certificate that is required by law. DATE: 11 Z`\ i'S Fill in please:, APPLICANT'S YOUR NAME%S: C-1ARV C-���M�11T i to BUSINESS YOUR HOME ADDRESS: 502-866-5 200 .VP4, TELEPHONE # Home Telephone Number r a rJ.S. r OCORP R 'ME F :. fr.. : .:.. .... ,: . _....... . ..... . . ....: .. .. .. . TY.PE.OF:BUSINES5:5i,J-nYlrvliIt;''t�4 ��:'.fat'hK111!�1vaS�,.%t�(F�; : ;4s�:�1��?z•�. NAM E.OF'NEW BUSINE5S4' ".+•'• --•.•••" • r. �.- « _ �'i ,i ES: - " C 'T(]N. - ;OC UPA I ISA:H OME '� - i} f CEL:N ER jTj - AR (. 1 :•ADDRESS:. - - When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town*of Barnstable. This form is intended to assist you in obtaining the information you.may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to-make sure you have the appropriate permits and licenses required to legally operate your business in this town. M\ � 1. BUILDING COMMISSIONER'S FFICE This individual has bee rmed of y permit requirements that pertain'to this type of business: . ' Authorized Signat0're* COMMENTS: 2. BOARD OF HEALTH n MUST COMPLY WITH'ALL , This individual has been informed of the :e� re uir m nts that pertain to this type of business. HAZARDOUS MATERIALS REGUT�Q1S. Authorized Signature** ; COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY] This individual has been informed of the licensing requirements.that pertain to this type of business. Authorized Signature* COMMENTS: Number Fee 1249 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that By the Seasons Pool Service 30 Rascally Rabbit Road, Marstons Mills, MA Is Hereby Granted a License For: Storing or Handling 111 -499 gallons of Hazardous Materials. --------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2019 unless sooner suspended or revoked. ---------------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2018 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health IoW1� of B ns able c� 4/ v/tf e Mato ervices g rY tKE Richard V. Scali, Director cj *tow } Public Health Division MESTABLE Mw Mw BARNSTABLE, • Thomas McKean, Director MASS. 1°�"o;��"S :r - 015 Office: 508-862-4644 Fax: 508-790-6304 -n APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALSy IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st—JUNE 3 Oth). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 x Vs, CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 67F O69of>3 2. IS THIS A PERMIT RENEWAL?ZYES_NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: l� mow. ec� l vl2�2a So v�S 5. NAME OF ESTABLISHMENT: ! Cea$o tit S Zh c , 6. ADDRESS OF ESTABLISHMENT: Aa!5c"11 Q44U, Arst)15 k5 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: k,o,I,S lJay e . Sand[w� c[, 53 S. TELEPHONE NUMBER OF ESTABLISHMENT: 6 9. EMAIL ADDRESS: �yfl�e s eosov�S lG�h.er�- C o P%-, 10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME g y PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: • NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE Q: / �App(ication Forms\HAZMAT APP 2017 REV c -NNW 5 Number Fee 1249 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that By the Seasons Pool Service 30 Rascally Rabbit Road, Marstons Mills,MA Is Hereby Granted a License �l Storing or Handling 111 - 499 gallons of Hazardous Materials. \ For: Sto g g ------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2018 unless sooner suspended or revoked. ---------------------------------------- PAUL J.CANNIF-F,U.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2017 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health '� TO of Unstable pKegula oervices Richard V. Scah, Director ' �T►�r Public Health Division BARNSTABLE 1 BPRNSroIIIE.iExilRVILLE:CONR'HY4Fl:IS 1AENSR,ABLE, !uas:crs vess 1639 vl4+,tiesl eunsrc RA� Thomas McKean,Director ":6,9_Zo, 1639.�a � 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 O�U/Lj?o?d`S Fax: 508-T0-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS DULY 1 st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons:'--$ 50.00 ❑ , CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 VS CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 02 1 OX 3 2. IS THIS A PERMIT RENEWAL? YES_NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGEIUSE OF GREATER THAN HOUSEHOLD QUANTITIES (2/5'GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: y Tk S['ct Soi., 6. ADDRESS OF ESTABLISHMENT: G SCa�<</ ��. 4rS 0° ,s 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: /( o2s3� 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: 10. SOLEOWNER: YES vl1G0 IF NO,NAME OF PARTNER: 6 iSlyd C:a&...,o,elro 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: r�Q aS c-Lnv-e_ CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE 6 )0 i Q:\Application FormsViAZMAT APP 2017 REVISED. oc t Number Fee 1249 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable c� Board of Health o � This is to Certify that By the Seasons Pool Service 30 Rascally Rabbit Road, Marstons Mills, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. ------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2017 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN - PAUL J.CANNIFF,D.M.D. 07/01/2016 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health a � N k t I Town of Barnstable • �t Regulatory Services Richard V. Scali, Director, 6 '"WIAPA Public Health Division BARNSTABL y/ 1639. `0�' � MR"ae�"uFmw' 'sT'a n Thomas McKean, Director `n� 1639-2014 200 Main Street, Hyannis,MA 02601 Office: 508-86274644 Fax: 508-79014 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1st-NNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26- 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 -499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ • A late charge of$10.00 will be assessed if paym ent'is not received by July Ist. ASSESSORS MAP AND PARCEL NO. DATE U W FULL NAME OF APPLICANT: ��- �� ;Q, wx Di elr-'7 NAME OF ESTABLISHMENT: V Ft Q�SOkLq Poo( Sef'VILe- ADDRESS OF ESTABLISHMENT: O Ro's4o'lix MAILING ADDRESS (IF DIFFERENT): 1(o k c: f Wo.V E. Soandwi'c l- M14 OZS 3-1 TELEPHONE NUMBER OF ESTABLISHMENT: �J O �(�$ — S--)00 EMAIL ADDRESS: bj 4 tLL Se-c sc)n S Co 1, ' SOLE OWNER: AYES NO IF NO,NAME OF PARTNER: . 1� �'S OF 5'aeo cl�GB FULL NAME,HOME ADDRESS,AND TELEPHONE# OF: sp-C'5o►..S CORPORATION NAME Ga 7 Ca;a,w.Fo ems, bu PRESIDENT S s Ste- 4.S Y2-'A' TREASURER CLERK • IF PREPARED BY OUTSIDE PARTY: SIGNATURE OF APPLICANT Name: Company Address : Telephone#: Email: Q:\Application FormS\IAZZAPP Revl6.docx Page 1 of aMEAd KEEPING YOU ORGANIZED No.10334 2-153L MWWUSA GET ORGANIZED AT SMEAD.COM ARCHITECT: SCHEDULE OF DRAWINGS G IAM P I ETRO ARCHITECTS a (j (�� T1 TITLE pHEEf 354 Gifford Street TEL 508 540 7400 z z Falmouth,MA 02540 FAX 508 540 0220 ABl AO-BUILT PLANpd & ELEVATIONpd - N Al ELEVATION A2 FIROT FLOOR PLN Q REAtODELED 2ND/ LOFT PLN w A SEdTIONO/LOFT FLOOR FRA"d PLN a z HAIFAa h all us. Z ow RENOVATIONS TO: z a p BY THE SEASONS �> UrA RASCALLY RABBIT LANE W MARSTONS MILLS, MA . OF ABBREVIATIONS SYMBOLS DO NOT SCALE FROM A& wdics=r aM roar a1ncaa[i.l 1�tlo�sea�Eft1 L aetr Cor roo,wm rryr d"a•. PiaW P� >a� Tw 1"sr AWOmumIR somef� ' m��e'r oi Paofmi ma DRAWINGSAL T m Tao1 ffi COMM maMRim �w aJ rzv,* �. .Lee rsirpPorearAaai THIS DRAWING IS PARTOFACOMPLETE ■ �°• � ARCHITECTURAL SET.THERE 1S&Aa a�emi3:•� �� ® 16--WffOd- INFORMATION PERTAINING TO THIS m �"` �� ® anode wahs DRAWING ON OTHER SHEETS.REFER ® ,�� TO Tl FOR COMPLETE SHEET LIST. DOrr a(lorrua�_mi NOT DO TAKE OFFS,BIDDING OR *1400 Law a ma FA an sobo uw � le1C Q) c� ® uplaknow_wr CONSTRUCTION ON THIS STRUCTURE : rRiao. k �om ,m vm�d n�a , tom rum WITHOUT A COMPLETE SET. r aeo0ia "'° ao�ia one C�f„= GENERAL NOTES MASSACHUSETTS 4.The deneel dontra•ter own.•ri y an dimam9mp at the ote and pies netlfy the 10.The done al drntreatar Owl!#ubmit to the Architect tar review and approwel,oaP dr-tao Architect at cop dicr pancW betas•proceeding*th the tack w v®.�Ow#I"y� In per,�y COMPLIANCE L The dmael danmuanli Mtat.that the dantraat Daamnmd are eomplhemtaq. ar 44 aga+c�t.verify critical dhaenow"in Abe neld before femiathng Rio*wch t t�roe U10#trne°tffrnatm s e g.Pevvide the lrm dog/ef a I�apldaheleettpl ltegyaered 0mssyaar to lnyont.Msreotme m vise �'add O0 °slon' tic/dmiog oaao . lm •reo dlht�eotlan itg.g.g ehiltled (WFCM) DRAWING TITLE: pban e/tebllphed by a AD #a< iooaua w Astir 000ar and are nos n.00#arib r4orin m the s'bo(�dayM m advm notify the Architect/Engineer ef eaqu6ad mrpatfanp at SHEET and e�tahilah •le.ailmll.lBeweUan ef floes be -1T•The dmeat dontractar Pull Arehitat rdth etevetlm iCfmmastan Provided>� - a she dmeaei dontractar fa reapmalDle!or an the'bork. a gee Arohitatmet Doom la An*enuntk t gomanteeM.and Mevla mdntaoence agaceaentll loran o®enae rdtn A.Build and W"Pets ef the task level,Pbunb./passe and in aaraact pardttam. govern the k*& ef an Elatr[col and ll(eohmtoai Hmpl or guarantee pe of the occupancy riod links Ma that the can.•hip c.c.s..1Ln alre ef she teem (� frl�taned as a pert ef the ar'k. DRAWN BY: a Hake 1ahiy1 tight and seat It Mach Ar hoPoww-apply mWdlnA Mealent or other T. Remo rhioh are not to be removed and are damaged or removed in the oom�ae to. ftw To BE Pmwk m AO PAw or 7m dziumAu dvr0mcinew: - 99 joint 4cetmms e✓dirdamp d by Ark itect.provide of the terk 0"be repaired and replaced in Mm nee emetic.'bftthohi. A. mania*and to male•the aterior CHECKED BY: d matey *hick we not ace tfona he T gal enla faaumtlon lnes'bem different - aPentngM Mlda ef the baDdiog tight w'basar end meteW vrblah ere not adlaomt m she��/cal.. a Ong/mfaoal dnrtrng the oom�ae ef sire fork�be r•cmlltruoted and - Air entry. � � D.Apply w fir4h so poet/at the tacit before can....them. fins e®mpse, 00fin sO l°�O�0k 1�ui� theII W e a1�•d d manna a Provide adequate heaark t t �ta-mtypi�" tau& in�etaD pain to*bah-34 glaring 0opK gang cebb•tK and herd'bam autoagl before aM te proetd• ma time/ firs eefhe affected of the work ��� DATE: !E-la-l6 hanging do-%and patut corrodible mounting platen before b0taning pargl owes teem. 0.An vadda crated or Mnnrfaad dJlrbnbed reMCsting hem aattlag.removai er lairtanetim ef iOaD be ef e VfM not Mablaas te d•faiaaslm or'beakmrng as the r'eMalt ef C*hers aoaepllmiea are required in order to inatan part/of the fork in arable farm el®myl no Part at the tacit i1ball be filled and>'h,¢hed W match a4cfatog conotruoHm, embc®antal omdWmyl or grog. REVISIONS: and to nuke she torn Petem Properly,Pie pacb aeoor krl%,L it/pedal toot 10.ltzcept all Provided in the Doaamen4t no hhall be sus d Pafurm aaWog and patchtng far an tradat Pasch hoW ft daatK omaast.P1P0 ars reached to maintain.adJdt and repair pnodadK provide them. 'bithout'bAstm approval of the Architect. !h•daneai daatmotm (�eR coordinate an and other Product/po*tWva�or his being moved from e�ttag eomarnatlan. . 1.ybno'a mmaraotme�{pl ldhvotlmr for a bnog, and aaJuatmg prodaota. cussing and ahan.adwW the Architect o1 any Potential aam0tagi vdsh ne+or a>datmg D.Provide aha/e',furred MpeoK trmobaM, eorer}�PfUt femmdatlmM and other Do cos 1nMtan prodoata 1!a mercer oonhm7 te she maantaohnQr'a m xvatlaa oReactms. conch aaam requtraa m com,ancnan'bfth the fork. 8 Mash oomrtrvottm iM not . d.Ad>oat and operate all R®a=No autharbied in Az! �of equipment.leaving them folly ready for ua•. U.Demolition dark ImaD only be mated ens once all temporary liming and bracing fa in a Provide�coordinate ew doe'/Dra*lugK coordinate and Peon/Wi required for aoca#Architect far ozo and to equipment a The 41doon of she Docmeatr Into AromtecturaL 6hacsual IDabiord,sfachenioeL Piaee.Removal Of an t-*--!MCPPe'41 pfan be completed aly after wr*am to Peer requiring a4u0tmm4 WXPectian,mmnta mew or other swop and aM required for aooeMlf PROJECT No. Plumbing and ohn oamponent/bi not intended ao dlvi�an of she*ark by trade or and complete. - rpaaeM nos otharefMe nooeMnBhis,aaab er attlgl and scar MpaaeK 1543 otha�Y- t8 An maserfaii•.egdpmms and'bmlunauofp"omforan to the regrdreme tO of p• Drs'blnIDt and menMaatvemvl'literature far rega4mentO for bep*pact and L Provide vtDtb inAanationr from lot Hoe to home lnolcdiog underground electrical, authortttea having 1or1/dlatlen.of the'fork. other Mupporting MtreaturvM. Provide Mneh MtecaturcK Remove pupporting Mhaotmall SHEET No. water,telephone and Ld&v to comply'bRh an tool coded and regalrmensd 1a AD meterlela a egdpmmt chef/amply'bRh sir• fiend and Health Act. d, vdsh removed equipment and patch s repair scald and .1.dmasts phall haws ompaeppiw0/trcogtb of e000 pal•Ply days for'bdld Ana peat Peat of one year*arwmty llpeolded.in she deneal daendt door pails Ply fto fat I�'bask.and reinforcing cad'B'bo m'blre fabric(**1) Inclu�an fly' other damage+bigh Coeur ar a IVOR of Mewmmt and pbrinkege during the fh}a yew Par dre'b4rg4 there noted,Provide he'd/tee►trod 11°i�an OabfL - 14.An maserida and equipment alien oantaam to she regdrmmta of aashori"having after 19u6Mte dw an. - DamPPra�g�be fart-y menofactued rent-inotic oono#—W from a0hattp larladfatim regarding not ndog or imitalliog aabeasca or aabeataa-amsawog materW gn. An'bark mall arm w sb• at she Datnoa ear she and mineral ffbe},and hnrtalled an an"and taattugr. to paint man ma . �n te Bonding Outaaabetlanal Rgfld®fJ i sp T1 PI"for deck,.Mhall be.concrete fined ganasnbe farmp. T ... °r°d OOII add0ebn PheII courcrm to A.x r1• fto-ft dly V f sloae far one- ik cam+far Paint«and datfa@i to dldldrm to •Dry Film Toddity. '"°'' '''°1nd�'mod DO NOT SCALE FROM DRAWINGS . PON su a ] a o a Fin" EXISTING FRONT ELEVATION EXISTING RIIGHT SIDE ELEVATION SCALE+ 114' P-0' SCALES 114" II-0" Fo EXISTING LEFT SIDE ELEVATION EXISTING kEAk ELEVATION SCALES 114' - P-0" SCALEs 114" P-0" 6TAIRG ® I 4'-1•wm Au PANEL 100 AMh 1 lLEGTRI e'-e• I EXIST. ---I--\ wu r wAu i LOFT PTECH.' I 1 M i ABOVE MOUN eruro N ID normAeo ® s rT i TFT 1 1 i 3i I I I I I 1 r r--- - I I I 1 1 11 OPEN 1 C3' G Y I I I I I 1 I cam•ceILING �— UPPER SPACE 9 cGTN�I) taLING) I Va"T. I I AIIU I 6Tca Ur MMOW=r I I 4-4•saeewAu. EXISTING FIRST FLOOR PLAN EXISTING SECOND FLOOR PLAN SCALE- 114" P-0' SCALE- 114" V-0" $ ° ' S p ly t ARCM' cr co SULTt>'u m #4o.4 � � `� 5 z Pg}a>4 Architects RENOVATIONS TO: , lo � e ��` � 354 BY THE SEASONS sA.— � G � RASCALLY RABBIT LANE - 0 � Falrnouf!z Tv1A� 0254 MARSTONS MILLS MA 1 W A #''tx s I€ 020 SIGNATGRE"'i�"w� �SIGNA7'URE I ■■■ ■■■ ■■■ ■■■ �MEN ® !■■ ■� I . • Illllilillll W == , .. M] ,. 9 ELEVATIONS _�� IIIIIIIIII . :Boom _!1-------!! I - '� - - d z CZ7 0 U Mawr. wrAnm sD u z s ' M EGH I I c ROOMm i------- ------- Fi9le ami w" mm r.N RPRAMe TO r.l awcnwL. W 777 I A I I----- I III I (IOb'GMLRW ) I II g V1 az r- -- OPEN ----- SPACE O ---- z ------ MO ST. zr E-+ z W a I s �Ei4� FIRST FLOORS #LAN SGAL.Es 1/4" V—O" C. s•Alla � .K EXIST. lin He IA0CV9 mw . }� Ia�r Awq/e cn SPP E r CR -a same n sacwer aoeet KUL— CLcacr ;..'• i — cau►w) SAVE STORAGE GOVO11 - ' 11' aw r K ~ - DRAWING TITLE: � 7 REMODELED a"T•r o 8 5 n T• G��U�ID/�00�pdU� Mawr- ------------� swwr 12 0 A? m airn 6 - LOFT DRAWN BY 1Tfl DQW : BREAKFAST - - - He++ru - cllEcxED Mf16TISVG tart ABM--\i NOOK "um DATE: KITCHEN He MCWATM r _ wws raMGaw © © LOrr A5WZ _� I REVISIONS: © © I I j A'-4'1GImmWALL TYOfQ10 e� or-atPROJECT No. 1543 REMODELED SECOND FLOOR FILAN REMODELED LOFT FLOOR #LAN SGALEs 1/4" t'-0" SCALEi 1/4" P—O' � °fl"" Tl . SHEET No. A2 - h z z � micas vvamr N ZW w,AFTw IoD Qlo °✓na rvc au � �c 'Z m �MILIM s mae w Irl' V1 mwno nr.NlAOOa . M DE ED i ✓~ EAVE oneTlNc M'ORAGEerlenNc ' ewar $ --- -- •---- •- - - W �. ---------- � z f 1 $ rc DtIST,N6 ---- I I ccMaecTar II O � .... - = M a oaT�ISION a`;R I NEW KITCHEN \�'T � z mr. o... .__ --— -- —— — ................. ----— �" zn me nmG=0 FLAMM-aer V] NK z ----=-- H ¢ _----------- O N S G —� OPEN SPACE --------------- extwrm s�- CMonN6 ryw[FLMM B SECTION THOU STAIR.5 A3 SCALE: 1/4" I'—O" (2)SECTION THRIU NEK HOUSE A3 SCALE, I/4° 1'-0° 1 21 nJ o II iGll o a n a o a o 0 o a n o n - DRAWING TITLE: c�JL�ly41 ONS/ swat LOFT FLOOR FRAHM PLAN III - DRAWN BY: J __ __ __ __ I CHECKED BY: J4 ZZ N6i J016T - DATE: 1E-10-16 •16,as REVISIONS: a .n 1 a 1 p a n 1 0 A tl PROJECT No.�wra 1543 06 !1 -1' - •ca�ie �rusr.w�mrmr�re • LOFT FLOORS FkAM I NG PLAN . SHEETNo. SCALE+ 1/4" 1'-0' A3 II III - i ; I - I - I (l ���`�% �1/� lr v v�a� •\��,� —1 a3 ! 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