HomeMy WebLinkAbout0031 ROSS LANE - Health .31 Ross Lane
A= 123=037- ;
Marstons`Mills
A v ` WN OF B STABLE nn�
LOCATION " .# SEWAGE # — V
VILLAGE A. ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY DD oultna
LEACHING FACILITY: (typej2oViaLZerAlto
NO.OF BEDROOMS
BUILDER OR OWNER �T hn �C�( '(') ' "JfL
PERMITDATE:-S"CD ' COMPLIANCE DATE: 2 f ""
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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/VAfi(;. TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of
OFFICE HOURS
l/ PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. • 200 MAIN STREET 3: O -FRI.30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MN.
MASS ON.-
�OrFu 39.6. HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY
FOOD ESTABLISHMENT INSPECTION REPORT
Name Date Jype of type of Ins en ction
Operation(s) Routine
Address nA Risk Food Service Re-inspection
Level Retail Previous Inspection
Telephone Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast r
In: Other
Inspector. Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with,Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices Blue Items
( ) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items)
Non-critical(N)violations must be corrected immediately or Corrective Action Required: ❑ No ❑ Yes
within 90 days as determined b the Board of Health. Overall Rating
Y Y ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations. If,no critical violations observed,
25.Equipment and Utensils (FC-4 590.005 9 or more non-critical violations=F.
)( ) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4non-critical violations
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 4 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations=C. refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dumpster screened from public view �-
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Si ture L Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
• ,. ,.-ten,: _ � , . _ _ ,, r� �. _ :�-.� �,.,. ,
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions o.
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
2-103.11 Person-in-Charge Duties - - _ Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 • ,PHF Hot and Cold Holding.
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
` `EMPLOYEE HEALTH - 3-302.f1(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) *^-
2 590.003(C), Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
7-102.11 Common Name-Working Containers*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
pP *
A licants 7-201.11 Separation-Storage*3-302.11(A) Food Protection* 20 Time as a Public Health Control
3-302.15 Washing Fruits and Vegetables
590.003(F) Responsibility of A Food Employee or An 7-202.11, Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use*_
3-304.11 Food Contact with Equipment and Utensils* - 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions*
3 590.003(D) Exclusions and Restrictions* 3-306.14(A)(B)Returned Food and Reservice of Food*
7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
1 t, Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 1 Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate.Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment* Not Otherwise Processed to Eliminate.
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg"°e I11/2001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155'F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency r f cesSanitizationEquipment*
of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009 A ( )-(D)in cater-
Chemical ( )-(D) Violations of Section 590.009 A
Sources* Ratites-165°F IS sec* in mobile food,temporary and residential
10 Proper,Adequate Handwashing g� p �'
3-401.11 C 3 Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By ( )( ) p
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(I)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
5 Receiving/Condition g� g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30)
* 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel 7 FC°-2' :003 -- ftk:
3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
* 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention *
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices Within 4 Hours 26. Water,Plumbing and Waste i_ FC-54.,. .006
27. Physical Facility FC-6 .007
28. Poisonous or Facility
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability Toxic Materials FC-7 .00
HACCP Plans 6-301.12 Hand Drying Provision Special Requirements .008 28.
3-502.11 Specialized Processing Methods* 9. Other
3-502.12 Reduced-Oxygen Packaging Criteria*, 130. 1
8-103.12 Conformance with Approved Procedures*
S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. - *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
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TOWN OF BARNSTABLE BAR_W 11��0
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager 1ej6vA1\ ,n rr/ t 1,.
Address of Offender '��"a�r�,, Ly''\ MV/MB Reg.#
Village/State/Zip
Business Name am/pm, on r 20_
Business Address (VN o'\ -'e., :^;7
Signature .of Enforcing Officer
Village/State/Zip
Location of Offense
t,C<5 t 5 r7/ •. - "+fit, , [► ( , �{ e�+ncvH,� (,j Enforcing Dept/Division,
Offense l rl ` =t/ a Vita t� `� �. ���„x �a lr '`a Zr e
Facts &V11 W4k 1.1tt h J c-A'7 /N-\ 1 cN k 11f V/'.-( 0,
f 4 y t
This-will serve only Cas a warning/. At this time no legar—action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town. -- •- h �,,1'} � (�i 1 viA-15';
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. L Y -5
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7)' TOWN OF BARNSTABLE BAR-W r
1
Ordinance or Regulation
WARNING NOTICE
Name of Off ender/Manager job'wc t"--1-� Y e / ,-,
Address of Offender 7 C� �Ca {.r b ` MV/MB Reg.#
Village/State/Zip 0 % e V)\ A L I
� r "
Business Name am/pm, on 20_
Business Address 1AA } �� It/I. tV') 12- <` y
Signature of Enforcing Officer
Village/State/Zip ` �
Location of Offense (; `- � l d. r '� A 'O'VY1
•� �-� r, � €r �rs�t Enforcing Dept/Divis26fi
Offense
Facts fa ov 11 r 1 =-Y. t't -t`'� ,i l:. #�!4 ��;.� #..�"`t!` �+�,. k t!'r i' r'E t�! �/ :a. r-~� �"�GCf/ �+n✓�—�
`xr' ,fi `► t. r<'/t, life + ti"�.. i �/i: 4-t, ��v�f,7 �E./�`' C6'� �,i "�. �!'�t i ���Z Ir"` �"�4� k a''t�� �,,i!#��.,t �fk�r�,�
This -will serve onlyLds a warning? At this time no legal- action has been taken.
it is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts tdL- gainvoluntary compliance. Subsequent violations will result in
appropriate legal action by the Town. -i-L'tt '5 t1r f t^ (
` 1
WHITE-OFFENDER •.CANARY ORD./REG PROG PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. J w-<
TOWN OF BAR STABLE
LOCATION SEWAGE #
VILLAGE ' AL—ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type - )
NO.OF BEDROOMS_
BUILDER OR OWNERS a 11 PS
PERMITDATE: S 1 -_6 — EL—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)
Edge-of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
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THE COMMONWEALTH OF MASSACHUSETTS
Entered-in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for 10igpogal *pgtem Congtruction permit
Application for a Permit to Construct(,,/)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. { ,Of S 1 05 616"11� Owner's Name,Address and Tel.No.
AA01 �✓1S ►^'���IS Joh►q rott, i Trusrce'� Halnhom rliy ,-Ws;
Assessor's Map/Parcel 12 3 'S^l P,O, S O x l 2 2 q
s rAQ, 02601
Installer's Name,Address,and Tel.^Noo Designer's Name,Address and Tel.No.
lF
" Arne H. Osa P,E. P�pis,pvwn L'aPg
LJ En9;Yleeri✓� rh
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9 3 y a' Sr` ?� o ✓+/"
Type of Building:
Dwelling No.of Bedrooms Lot Size 2�,L05 sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow C> gallons per day. Calculated daily flow 3 2 gallons.
Plan Date 1G6 ICI I q°r7 Number of sheets I Revision Date
Title 5i ar)d SCWA lai h of L07"I q' 6"5*r DSl ee'(1d i e— Nngr!Sro M,'!l5
✓�Alcictini Ze+' �i✓11'i1��r-o�'
Size of Septic Tank 5� �S�O Type of S.A.S. � ,7
n S,L, %FY, 5- �/ '1
Description of Soil d-Ca Sy)d�,. Coop G - 3 2 8 L Sd 1 b Y, 6/�Q , 3 g� C/
cn, S 2.5-1 s/y , g(-'1- 1.3 2" C 2 m S, 2
A S« Le rti o✓) (�� ,� � s` Ia.SS X Soy 1 S
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance oft d on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Co nd not t a et ys in operation until a Certifi-
cate of Compliance has been;issued ithis ABrda if Health,
Signed Date g
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 97—/0 ® Date Issued '�
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ivo. 17'/0 U 0 � F x . FU U; o0
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
01pprication for Migogar *pttem Construction Permit
Application for a Permit to Construct(Repair( )Upgrade( )Abandon( ) []Complete System ❑Individual Components
Location Address or Lot No. I of - 5 r�57P✓v�l�t1O Owner's Name,Address and Tel.No. 7 7
nnu✓57oo s M, 1l5 -TO hri (-- CA10CC I ,sr,e-, Homhom �rhy 1w.1
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Assessor's Map/Parcel 1) { '�"� p O, 66 X ►2 2 y %
o o-60!
Installer's Name,Address;and Tel
/.�No.
� Designer's Name,Address and Tel.No. 3 62 -ySN1
6 v1� r ) {}rne ta, OJaIA P,E, P,I,S,
l/l� powvl CaPg Ehyiv�ePiir`�
q 3q Mu, ST Y r OLt Th ✓�
Type of Building:
Dwelling No.of Bedrooms Lot Size 25_sq..ft. Garbage Grinder( )
Other' Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 gallons per day. Calculated daily flow 3 V 9— gallons.
IE Plan Date Fc� 2`� l`/g'rJ Number of sheets Revision Date
Title Sire uj Srwa!i-f P/av) ref. L07- /q Cc4sr osrr,,t1d1e. R�� `vwre,TO
Size of Septic Tank 510 0 Type of S.A.S. w'r t e,,-"i h Fi/rvrtT'L,3
- Description of Soil am,^ L - 3 2 1 , S, l b Yr d/R , 9� /
2,S-q S/y . 9� '- �32" C� ILS� 2, sy
Sre Soi Looi o✓) P1 a✓) A C la S S T 56i 1 S
Nature of Repairs or Alterations(Answer when applicable)
p
�i
Date last inspected: M
Agreement:
The undersigned agrees'.to ensure the construction and maintenance oft .afore-deseRbi don-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Co nd not «p a e t yst in operation until a Certifi-
cate of Compliance has been issued Py this B and .f Health.
Signed Date
Application Approved by Date 9
Application Disapproved for the following reasons
t
Permit No. ??—/O O Date Issued
-- -------------------------------- ——— «
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS F
Certificate of Compliance
THIS IS TO CERT, *et the i e ` Disposal System Constructed /)Repaired( ) Upgraded( )
Abandoned( )by v (/
at /9 GS Q e%,.V 14(C_ A r ",3 S"s 3 37 has been constructed in accordance
With the provisions of Title 5 and the for Disposal System Construction Permit No. 0 dated • �� " 7
Installer Designer
' The issuance of this permit shall not be construed as a guarantee that the system` i function as designed.
Date (� Inspector +'.1�, �
i ----------------------------------------
No. 7 7" /O O Fee 6 V U'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLES MASSACHUSETTS
migogar -- pgtem Construction Permit
Permission is herebyranted to Construct V Repair U rade A and n
g ( ) P ( ) P ( ) b o ( )
System located at �9 S ' 0 51- -' � • 6 to S 1 k s
./23 �
If
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction , st b. completed within three years of the date o this permit. 0
j f
Date: / Approved by I%�
t
V \ 3
Engineering Dept.(3rd floor) Map 2 Parcel Permit
' House# Date Issued 'y _
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) fee
0
Conservation Office(4th floor)(8:30-9:30/1:00-2:00)
Planning Dept.(1st floor/School Admin. Bldg.) .w
Definitive Plan Approved by Planning Board 19 �:
BARNSTABLE.
�rED MAC A`�
TOWN OF BARNSTABLE
Building Permit Application n
Project Street Address is 10ou
Village MCAT S,W1 s ► 4 S All a
Owner Sohn FdJC4Ci T('Ctsr-ee Address PO, got I ` -')-q r"l�q►'►� U..
Telephone
So$ '771 3ff 6°1 ffarAhovo\ ea rr Frcj -
c o on"Ql
Permit Request 47p &.1d a �Si /e �a►^n<<�/ . 1 9ti� 5Tvy�� C�o�An� Gov?SisT(r)�-
OF geo( rbOIMS N�aTh sar�l Povoe ro hU,ice- V /"FejCo✓��✓ems
0wo or g,,? �t-O '6 GO►7//fO77(Allt/ r—Vaynm f wit Y1 2 DC�( �✓,115 ro h/ Lyr CC6 %4ear2z",Ps
First Floor U square feet Second Floor 00 / (. square feet
Construction Type C oyeOl-io✓)cc / Fc-a^,ij- WI `Z k`f �✓a-!�5
Estimated Project Cost $ 1 1000
p
Zoning District I� r Flood Plain e Water Protection
Lot Size �� O 5 Grandfathered AYes ❑No
Dwelling Type: Single Family !l Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes �JNo On Old King's Highway ❑Yes N(No
Basement Type: 14Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New �._ Half: Existing New
No.of Bedrooms: Existing New
Total Room Count(not including baths): Existing New G First Floor Room Count
Heat Type and Fuel: JJGas ❑Oil ❑Electric ❑Other
Central Air ❑Yes *No . Fireplaces: Existing New Existing wood/coal stove ❑Yes j4No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial .❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
Builder Information
Name Soh n FC4 IC4 cc 1 Telephone Number /
Address 0 , Aa I `�2 Y License# C)S'7 1 y
H wm e-)r?i.4, Iyl rat QUO ( Home Improvement Contractor#_ 10 L /O%
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
Town of Barnstable P# P ag Ll _
Department of Health,Safety,and Environmental Services
Public Health Division Date —
�, 367 Main Street,Hyannis MA 02601
RARPMASIX
Date Scheduled i a—( ^ / Time 10 Fee Pd. Igo
' Soil Suitability Assessment for Sewage Disposal
Performed By: ��(� 0JI� L.� � C Witnessed By: e3 6-1 L i V NN C�O1•})
L :CATI0�1 &;CENIRAIJtO�tl�!tATION
Location Address T 3 7 (1016 L,A✓ Owner's Name
e P 4A M1L�IJ
o �l..v�u.�
�T I IA less (�' ANN15 -m
p5 2S7/).7
Assessor's Map/Parcel: )2�j/?> Engineer's Name�W N CA•TE L�1�1trr-\ N
NEW CONSTRUCTION REPAIR Telephone#. —?'�(e2 - Li 5
Land Use N) N I Slopes(%) O P 1:7 Surface Stones
Distances from: Open Water Body ft Possible Wet Area — ft Drinking Water Well r ft
Drainage Way �s ft' Property Line ` ' ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
�j
2No•yy
3
1010
r
Parent material(geologic) Depth to Bedrock
i
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
..
l� TI NATr011 f. k S11�SONA�, �D't�V�TI R TAti�l
Method Used
Depth Observed standing in obs hole. A I /t _in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading.Date: Index Well level Adj.factor Adj.Groundwater Level_
PERI.
COLATI. N. EST uate IOIe
Observation —�
Hole# Time at 9"
Depth of Perc �P 1'�'•L �' �' ' Time at 6"
Start Pre-soak Time @ �� 1 h �Z Time(9"-6")
End Pre-soak
Rate Min./Inch VoN
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) 1
Original: Public Health Division Observation Hole Data To Be Completed on Back---�
Copy: Applicant
s
t
bEEI' C) SER' ATIOI�I HOLE LOG 1
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling Structure,Stones,Boulderes.
%
-3 T3 v Ytu 6/S
5,4Nv 2 Sy
-7/3 _
DEEP OBSERVATION H�DLE LOG Hold:# '?k :'�
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(m.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes.
%
S fts ! • 1 �
DEEP OBSERVATION HOSE LOG dole
. . ....... ... ... : .
.. .. ...
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes.
%
DEEP OBSERVATION HOLE LOG Hale:#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
%
DEEP OBSE W I TI0N HOLE I,OG 1IoIe;#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
%
—----------- IIIT V SEPTIC"PROF Tn_ TES HOLE ��IOGS.�� _T.O.F,,�AT TO SC omss COVER T6,'wrrHIN ir 'OF FIN.' GRADE! ENGINEE VA)ACCESSCOVER '(WATERtIGHT) 70� , R.IN ir, OF FIN.(CP I&O -PRECAST I% SLOPE REQUIRED OVER,SYSTI�M WITNESS GRADE WITH MINIMUM .75' OF COVER OVER �.j-%-DATE r DOUBLE WASHED PEASTONE RUN PIPE LEVEL PERC. ' RATE,�,FOR FIRST 2' .,f <MAX.�PROPOSED CLASS SOILS P# L rp GALLON SEPMC AN K� GAS z__z_ nT7 `7 SLOPE) IIECHANICAL CRU ELEV.(15.221 [21) 7- 2 COMPACTION.DEPTH OF FLOW X SLOPE) SLOPE) TO 1 112- DOUBLE WASHED STONE TEE,SIZES: 3/4 0 4r e-NLET DEPTH LOCATION MAP SCALE OUTtET'DEPTH. 4- LEACHING I, SEPTIC TANK D' BOX ASSESSORS MAP PARtL FACILITY ZONING.DISTRICT, P-f::5''YARD SETBACM I �'FRONT SIDE (5'4r REW o ta A-r PLAN, REF. 1_1 -1 FLOOD ZONE:v : "NOTES,1. DATUM IS :: ,.SEPTIC DESIGN: (GARBAGE DISPOSER IS -IS z DESIGN FLOW:,- E) BEDROOMS 6 ,�GPD' --N:=,GPD MUNICIPAL WATER 2. 0 BE� 1/8* PER FCfOT.USE A 3LJ!��GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE AASHO 'H-D T UNITS SEPTIC TANK, ESIGN LOADING'FOR ALL PRECAS 5. PIPE JOINTS TO BE MADE WATERTIGHT�l USE A 1500 ALLON SEPTIC TANK '. 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH-EN\ARONMENTAL,.CODE TITLE V.LEACHING: 7.'�THIS, PLAN S FORPROPOSED WORK 'ONLY -AND NOT TO BE SIDES FOR LOT LINE STAKING.:USED 8. PIPE, FOR SEPTIC`sysTEM, :.TO,,'SCH. 40-47 PVC.' ',BOTTOM: 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT TOTAL: S.F. GPD INSPECTION BY 8 OARb OF HEALTH ANDPERMISSION OBTAINED If ILEGEND 'SITE ANUSEWAt# r_ PLAN PROPOSED SPOT ELEvATtON' OF 1 0oxO EXISTING SPOT ELEVATION 'THE:TOWN OF IN PROPOSED CONTOUR Iloo — EXISTING CONTOUR PREPARED' FOR: e,0 BOARD OF HFALTH LE.- DATE: 115�lu SCA APPROVF.D DATE Ifla %a 3a 0 F o wni �AANE
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