HomeMy WebLinkAbout0240 RIVER ROAD - Health 240 River Road
Marstons Mills P
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROT CTION
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AUG 14 2002
TOWN OF BAr.,:
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-,SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ,l C
Property Address: 240 RIVER RD MARSTONS MILLS, MA 02648 6 QUO �J
Owner's Name: BARBARA PARKER
Owner's Address: PO BOX 173 MARSTONS MILLS MA 02648
Date of Inspection: 8/5/02 CURDY
Name of Inspector: (please print) ; . JOHN GRACI
Company Name: SEPTIC INSPECTIONS inc,
Mailing Address: P.O. BOX'2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813.FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.346of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally. asses
_ Needs Furt Evaluation by the Local Approving Authority
Fails
to
Inspector's Signature: Date: 8/5/02
5 .
The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this.inspe tion. 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 4. .
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****This report only describes"Iedrdi.tions 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.
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
Try
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 240 RIVER RD MAI STONS MILLS, MA 02648
Owner: BARBARA PARKER
Date of Inspection: 8/5/02
Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Sectio . D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE VjNSPECTION'.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes: `
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or,repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statement . If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection,if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)"are replaced
obwuctio'n is removed
distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4times a year due to broken or obstructed pipe(s).The system will pass
4.
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction s removed
ND explain: n/a
' I� �
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
t CERTIFICATION(continued)
Property Address: 240 RIVER RD MARSTONS MILLS, MA 02648
Owner: BARBARA PARKER j,
Date of Inspection: 8/5/02
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 Meet of a surface water
_ Cesspool or privy is within.,5,0 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the
system is functioning in.a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and$AS and the SAS is within 50 feet of a private water supply well.
_ The system has a se tic 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 n/a
"This system passes if the"welll'wj.ater,;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 a4 ied,to this form.
-A
3. Other:
n/a
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Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 240 RIVER'RD MARSTONS MILLS,MA 02648
Owner: BARBARA PARKER
Date of Inspection: 8/5/02`
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
i
Yes No
X Backup of sewage into facility .r_system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluert to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped PUMPED ONE MONTH AGO BY OWNER.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or pr`iSy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or.privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for.coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this forma',
_ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the systemyfails.The system owner should contact the Beard 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 desig:, ow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no",to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a s arface drinking water supply
X the system is within,200.feet of a.tributary to a surface drinking water SL.Pply
X 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"gels";to,any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above (lie hirge sys(clu lies failed. T'he owner or operator of any Dirge system considered a si�nificanl (hrettl
under Section E or failed under;SeetionD shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
n
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
1,
Property Address: 240 RIVER RD MARSTONS MILLS,MA 02648
Owner: BARBARA PARKER
Date of Inspection: 8/5/02
Check if the following have been dome. You must indicate "yes" or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period`?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X _ Were as built plans of the'system obtained and examined?(If they were not available note as N/A)
>1
X _ Was the facility or dwelli�ng inspected for signs of sewage back up`?
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X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS located on site
Y p ,, g ,
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 ?
N.
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 exarnple,'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)J
a
3 a -
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Page 6 of 1 I
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
.SYSTEM INFORMATION
Property Address: 240 RIVER RD'M'ARSTONS MILLS, MA 02648
Owner: BARBARA PARKER
Date of Inspection: 8/5/02
''FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(des igit)'.'4. ..,Nuinber,of bedrooms(actual): 4
DESIGN flow based on 310 C1VfR15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 4
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no);NO
Seasonal use: (yes or no): NO` . '
Water meter readings, if available(last 2 years usage(gpd)): n4i- 00— 131 ,000
Sump pump(yes or no): NO _
Last date of occupancy: n/a 0 l i S�1,o00
COMMERCIAL/INDUSTRIAL,
Type of establishment: n/a
Design flow(based on 310 CMR.,15.203'):-n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tanl(oresent(yes,or no): NO
Non-sanitary waste discharged'.to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records V u
E a�[1,,1'.; :k,i
Source of information: PUMPED ONE MONTH AGO BY OWNER
Was system pumped as part of thle inspection(yes or no): NO
If yes,volume pumped: n/agallons`;-How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy ;
_Shared system(yes or no)(if yes,`attach previous inspection records, if any)
_Innovative/Alternative technol,9gy. Attach,a copy of the current operation and maintenance contract(to be obtained from
system owner)
Tight tank Attach a copy of the DEP approval
Other(describe): n/a ;
Approximate age of all components,date installed(if known)and source of information:
Sl?('TIC SI,S"rrnl 3116 IlY N( R
Were sewage odors detected when arriving at the site(yes or no): NO
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Page 7 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 RIVER RD MARSTONS MILLS,MA 02648
Owner: BARBARA PARKER
Date of Inspection: 8!5/02
BUILDING SEWER(locate on site plan)
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Depth below grade: 18"
Materials of construction:_cast iron X40'1?VC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a "IS`Age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 150OG L 10'6"41I+5- W 5'S8""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum'to'U6ttom'0f0Utlet tee or baffle: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY'TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recon-in a£ndatigns, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leak ageLl"etc
,) §,
n/a
n ,
,, 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 RIVERRD MARSTONS MILLS, MA 02648
Owner: BARBARA PARKER
Date of Inspection: 8/5/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must`be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distriliut►on to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
D-BOX IS t STRUCTURALLY SOUND.- Y
?:
PUMP CHAMBER:_(locate on site plan)
s
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,;condition of pumps and appurtenances,etc.):
,..
n/a
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1i;1' L fps
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Page 9 of 1 1
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 RIVER RD MARSTONS MILLS,MA 02648
Owner: BARBARA PARKER
Date of Inspection: 8/5/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
I leaching trenches, number, length: 80
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Continents(note condition of soil,`signs of hydraulic failure, level of ponding,danip soil,condition of vegetation,etc.):
TRENCH IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF
FAILURE.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or nc) NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
n/a
PRIVY: (locate on site plan)"
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, sign( of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a �, y
Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 RIVER RD MARSTONS MILLS,MA 02648
Owner: BARBARA PARKER
Date of Inspection: 8!5/02'
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.
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Page I I of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 RIVER RD MARSTONS MILLS,MA 02648
Owner: BARBARA PARKER
Date of Inspection: 8/5/02
SITE EXAM
_Slope
_Surface water
_Check cellar '
Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
J
You must describe how you established the high ground water elevation:
HAND AUGER- 10+FT. .
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TOWN OF BARNSTABLE Date: IS--/
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
M
NAME OF'BUSINESS: fn'i4S-on-e P-eckc►niCc► ,
r.31
BUSINESS LOCATION: 1?46 Zier fd. INVENTORY
MAILING ADDRESS: P0. L�n 1-73 TOTAL AMOUNT:
TELEPHONE NUMBER: S2LL- ?7.-:? a -
CONTACT PERSON: ,e v-
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EMERGENCY CONTACT TELEPHONE NUMBE : 509-qLg-' 'q&6 MSDS ON SITE?
TYPE OF BUSINESS: M-eCkcihr( I / 14VRC.
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison"labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous(please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Appli t' a Staff's Initials
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YOU;WISI4,T0:0PEN A.:BUSI.NESS?
For Your Infor maG►on „ Business certificates[Gast$40 p0 for 4 years] A bu mess certfcate.ONLY REGIST(rRS YOUR.:NAME'in town_:(vvhich you K
must do::by:M:G 4 Jt does nOt.give:,00 pe iiiitanao operate)_ You must first obtain the necessary:signatures on this form at 200 Main St-:Hyannis.
.Take the completed form'to::the Town Cferk s Office 1st FI .3fi?tilain 5t: H annis MA 0260T: (Town Hall):and et the Business Certificate that:;is
required by law. Y g
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„�ti OATE I l lr Fill in p(ease:
y,f APPLJCANTS: ' YOUR.NAME/S .., ... {r'.. r•r� i;y
� + . :BUSINESS ..: .::: .:::...:..YOUR HOME ADDRE88 f
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TELEPHONE # Horrie.Telephone NUmber: o?
:OR EIN r.` C 5`�
1V:AME 0:1�GpRPORATION�
NAME O NEW BU5INE5S :>; TYPE OF:BUSINESS 2CIgn cc,. C t1�:C..:,1
1S:THIS A HOME f9CCL)PATIDN° YES ND
AOORES5 OF SUUINESS MAP/PARCEL IVUNfBEA — [AssesstngJ:
V1/hen stat}tfi0 a new business there:ars severijf,'thtngs°yoU rnusC`d icr'pT�der d.be_Irt compltenoe v+nth the rules end regulations:of tt�e..6 of
Berrtsta[le Th►s farm;is 14'endec(to:ass st you. ,obtaltitng _'rh :6fortrtstaorl you.nlayr rlaet�,. lrou„NlU.ST'GO TO 200 IVlatn'>St.-- (corner of Yarmouth'
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Rd, S Nlaln Street] tq.make:sure U.ha the appr`npriate pe.r..-mlts:and Ifearises'Fegwred::to legally apes•ate yrur business in this tdwri;
1 DU�t>?Ir�G co ISSIF1'SDF�=1C"` MUST COMPLY WITH HCSME OCCUPATION
This;lndit u.al, a In P. mir r` ctr eriGs tliat p�rrun to dais tjrpe.:iif business,. SAND REGULATIONS::.: FAILURE TO "+
PLY MAY RESULT:
--- ': COMP RES I�iES
Ut or Si natur:
M ENT
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Th1s noi5k al.Hes:been MUST COMPLY WITH AI.c:A
e o rrnit requirements that pe''rtatri>to this type of business r,
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HAZA DOU MATERIALS R
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Auth0riz E+ture*
COMMENTS' . (p0p1 1�1{2P��-3 ��
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3. CONS.UMEII AFFAIRS(LICENSING AUTHORITY W
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170 tndiwdual Fins been informed of f;he licensing requtrements:ahat pertatn'toahlstype of business ,
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Authorized'Signature:
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CDIVIMENTS :
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TOWN OF BARNSTABLE vl�
LOCAT10N Vl r SEWAGE # 9S- S'4!-
VILLAGE IPA_esro 4S l�Ll,'lLc ASSESSOR'S MAP&LOT 6&0 olS—
INSTALLER'S NAME&PHONE NO. 77—03�`! ✓0,��l�Zi �.Gwf3.�rts-eoS
SEPTIC TANK CAPACITY 1500
LEACHING FACILITY: (type) re1546.4 (size) I/ X 2
NO.OF BEDROOMS
BUILDER OR OWNER RDlolier Fe4i^` iyvl
PERMITDATE: COMPLIANCE DATE: B
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and.Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facili ) Feet
Furnished by
M
r
No. n szo �; .. - Fee ff 1�=��-'
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIPPfication for jBioaar *patent Cow5tructi.on Permit
Application for a Permit to Construct( )Repair upgrade( )Abandon( ) Doi mplete System ❑Individual Components
Location Address or Lot No. 2 4o0 j V.,Zr1. Pe/, Owner's Name,Address and Tel.No. C1 Q$— 2 9SO'
i9914^sm-os 4f"ZIs �Zal���rf �iaa r
Assessor's Map/Parcel �.
0(o of
Installer's Name,Address,and Tel.No. 4 71— O l el f Designer's Name,Address and Tel.No.
r/BS 6XA-11-0e5
1 07, ice,f S
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
-
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alt rations(Answer when applicable) /moo%� �zaf/�,�i v i sung� ctlir4
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu d by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No Date Issued
No. " " *' Fee
)THCOMMONWEALTH OF MASSACHUSETTS Entered in computer:
'• Yes
PUBLIC HEALTH DIVISION--TOWN OF BARNSTABLE., MASSACHUSETTS
01pplicatiou for Mioozal *potem Con.5truction Permit
Application for a Permit to Construct( )Repair upgrade( )Abandon( �) Complete System 0 Individual Components
Location Address or Lot No. 2 yd ��� / Owner's Name,Address and Tel.No. 41 a$-- Q 4r/BS
MmA*SMHS
Assessor'sMap/Parcel
040 _01Sr 2,yv
i
Installer's Name,Address,and Tel.No. 4/71- 01 y 9 Designer's Name,Address and Tel.No. U
Type of Building:
Dwelling No.of Bedrooms / Lot Size sq. ft. Garbage Grinder( )
Other Type of Building f No.'of Persons Showers( ) Cafeteria( )
Other Fixtures f`
Design Flow A gallons per,day. Calculated daily flow gallons.
Plan Date /,Aumber of sheets Revision Date
Title
Size of Septic Tank ' Type of S.A.S.
i.
Description of Soil
.t
r `
Nature of Repairs or Alt rations(Answer when applicable) , i,$r�,���.- ��.roG►�� �ui�'
zle,e c ," rr' ti,c.4 �A 5�X 2-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health. ,-al
Signed Date - —ex
Application Approved by Date "
'Application Disapproved for the following reasons "
Permit No. `Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (upgraded( )
Abandoned( )by
at a has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. < datedA " 4 —4S? .
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the syAeio will funct' n s designed.
Date —7' c7 Inspecto
No. 9 y,./a G� --------------------'Fee �i.._ ..___.....
THE COMMONWEALTH OF MASSACHUSETTS
u PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
f Migpool *proem Con6truction Permit
Permission is hereby granted to Construct( )Repair(,r.. grade( )Abandon( )
System located at 2 4/0 Q,V.=r*- A41
and as described in the above Application for Disposal System Construciion Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Constructti-onn must be completed within three years of the date of thi it.
Date: lei' �..7 �� Approved
r P
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only:
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
ASSESSORS MAP NO'
PARCEL
hereby certify that the application for disposal works
construction permit signed by me dated ?— S 9z? ,concerning the
property located at 2yo f2✓rTH Q�/ ALlAelsro`.s l�I�yl meets all of the
following criteria:
i
A,--7'hete are no wetlands located within 100 feet of the proposed leaching facility
X--There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
j
There are no variances requested or needed.
I
If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the i
proposed leaching facility will n-ol be located less than fourteen(14)feet above the maximum adjusted j
groundwater table elevation. i
I
Please complete the following:
i
A)Top of(around Elevation(according to the Engineering Division G.I.S.map) 32, f'
i
B)Observed Groundwater Table Elevation(according to Health Division well map)2
SIGNED: DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BAR14STABLE NUMBER- -
[Attach it sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
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TOWN OF BARNSTABLE
LOCATION /ZJ SEWAGE #�8- SDG
VILLAGE1?�I��sroHS !/Ll,lac ASSESSOR'S MAP & LOT_D(�_
INSTALLER'S NAME&PHONE NO. 1-177-c3 4l j
SEPTIC TANK CAPACITY /S"90
LEACHING FACILITY: (type)_L r14eff �,•��%ham' (size) LO X q X 2
NO.OF BEDROOMS y .
BUILDER OR OWNER 1o�l=d�" --r ,<l=y'
PERMTTDATE:_F- t-- 98 COMPLIANCE DATE:_� - 7- y g
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facili ) Feet
Furnished by _ ,
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