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Home My WebLink About0866 SANTUIT-NEWTOWN ROAD UNIT #A - Health 866 SANTUIT-NEWTOWN ; �- A= 028 099 y '(a o5 1 i I jq p TOWN OF BARNSTABLE ` LOCATION SEWAGE # VILLAGETU•✓,P �/� ASSESSOR'S MAP& LOT 9 INSTALLER'S NAME&PHONE NO. o SEPTIC TANK CAPACITY 6.AL - LEACHING FACILITY: (type) �d ai Df2c��P( (size) p � NO.OF BEDROOMS__I. BUILDER OR OWNER a ra G`��aai PERMI TDATE: 3dh/F i 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 Feet i 8, J` s u j 7 — —� �, �O 1/6/99 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 DESIGNED PLANS) s I, 'JaTo%I hereby certify that the application for disposal works construction permit signed by me dated ? &AY concerning the property located at_ (�(� ,�,�,,, /Zp /t/",0)r /1-1C'r meets all of the following criteria: V • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. �• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. �• There are no wetlands within 100 feet of the proposed septic system V• 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 �• There are no variances requested or needed. J • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: 9 f A) Top of Ground Surface Elevation(using GIS information) p- B) G.W.Elevation +the MAX.High G.W. Adjustment. C ' _ 4—d DIFFERENCE BETWEEN A and B , SIGNED : DATE: �� [Sketch proposed plan of system on back]. q:health folder:cert SUBSURFACE'SEWAGE DISPOSAL-SYSTEM,INSPECTION FORM 1 1/ _1 Address of property: 866 NEWTOWN ROAD Owner's Name: DIVERSIFIED PARTNERS s f`v• :, Date of Inspection: JUNE 23, 1995 �o PART A �l CHECKLIST Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. r- . r.lc '(;! .li 1. ., r, i. ."Ir' a •i l :. r+t 'd. ;i�r}:� 4 ,�. ,x`r, .� �,..�a .,' *t '�t � ? t '.i�= r X 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 Vol"limes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. P'�'3,..A, t:.R4.e.•;4A ,t4 f, ` _? . ., � 9� i. :r... "r)-.. '3 '.:i,71 4..i 'r.:=J...i: ::�it,ii' •L� X The facility or dwelling was inspected for signs of sewage back-up. X The site was inspected for signs of breakout. X All system components,excluding the SAS,.lave'been located on the`site`' X The septic tank manholes were uncovered;'opened;and'the interior"of the septic`tink:was` inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS'on�the sift has been"determined b"ased on existing`information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owners)were provided with information on the proper maintenance Hof SSDS:' .try{i•{Cir {>t (t �i. `»!3 r £<rt'r1.1 , }'...1�i,la{'S£ "J!(.i r s.:St_ .+y'ri (qr 3 `O`!" ��. -rr` :4, 1996 ie� c � �t S � SUBSURFACE SEWAGE DISPOSAL SYSttM'l14SPECTi0i4 FORM 2 PART B SYSTEM INFORMATION FLOW CONDITIONS` IF RESIDENTIAL 3 number of bedrooms 0 number of current residents NO garbage grinder,yes or no P� I"tJ i ,., YES laundry connected to system,yes orno , NO seasonal use,yes or no T-) IF NONRESIDENTIAL, CALCULATED FLOW: WATER METER READINGS,IF AVAILABLE: HOW WAS ON PRIVATE WELL;CONNECTED TO C-VILLE/OST.ON 6/22/95 , Last date.of occupa py GENERAL INFORMATION Pumping records and source of information: NO PUMPING INFORMATION X System pumped as part of inspection,yes or no if yes,volume pumped , 1..000,GALLO r! Reason for pumping: ND EXCEEPEI�,SCUMA SLUDGE,,T OLDS. Type of system X -,,,.,,,$eptip..,ta*-Oistribution.box/soil,absorvtionsy�.stem, .,(-NQD-B QX Singlecdsspooi Overflow cesspool ,Privy.,,. .!W 0 _ Shared system(yes or no) (if yes, attach previous inspection I ecords: if=y)*,---,:-. Other(explain) Apprbximite age o,f all components. Date installed, if known. Source of information: 4/8/76 SEWAGE PERMIT ON FILE AT THE BOARD OF HEALTH NO Sewag6 odors detected when arriving at the site,yes or no? �1 A Ate SUBSURFACE SEWAGE"DISPOSAL INSPECTION FORM 3 .+� : . . PART B SYSTEM INFORMATION continued SEPTIC TANK: X (locate on site plan) depth below grade: 8" material of construction: X concrete metal FRP other(explain) dimensions: 4' WIDE X 8' LONG X 4' DEEP 19" sludge depth 5" distance from top of sludge to bottom of outlet tee or baffle 15" scum thickness _ 1" distance from top of scum to top of outlet tee or baffle 5.5" distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for puriiping;condiiion of inlet and outlet.tees or�baffles,`'depth-of liquid level relation to outlet invert, structural integrity; evidence of leakage,recommendations for repair, etc.) TANKrHAStBEEN PUMPED AS A RESULT OF EXCEEDING SCUM AND SLUDGE THRESHOLDS; LIQUID LEVEL IS AT THE OUTLET INVERT; NO ADVERSE INDICATORS. DISTRIBUTION BOX: (locate on site plan) 1 y ?. depth of liquid level above outlet invert r. A ry Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,recommendation for repairs, etc.) g' - '• , PUMP CHAMBER: (locate on site plan) pumps in working order,yes or no- Comments: " (note condition of-pump chamber,condition of pumps and appurtenances,recommendations for maintenance or repairs,etc.) I DISr ASSUBSURFACEfSEWAGEOSL .YSTEN a; AECI o N. FORM 4 r_ P I .ARTS. t B .t. TtM SOIL.ABSORPTION SYSTEM(SAS): X ' + (locate on site �GKMATION continued Plan,if possible;excavation not required, but ma y Y be approximated PP0 ximat If not determined to be present,explain: by non-intrusive methods) FF .. r ,i ,,, 'iY ! t .. ...'1 ..i�;,•fr .i`!. j: .. e IeS k' . ..r�,.e. , Type _ ... leaching pits and number leaching chamber ONE LEAC 's.f ` s and nu HING P leachingtuber II',E11'PROX.8'DIAIVI X 5'DEEP galleries and number leaching trenches,number,dimension leaching n ensions overflow fields, umber,dim r. • , .,s' '�„ - . r'x .�'tr .. -'`,. 't_ cesspool,number Comments: (note condition of soil' signs of hydraulic failure, ,'' :° ,R:'s, . `t^, ,f x c•, r . .:. or repairs, etc.) level of ' I r pondin COVER IS 18'BELOW„ g, condition of vegetation,recommendations for maintenance' "�t THE INSPECTION ` f'GKADE;r BOTTW OF PIT I3'l16 „i, r 4 BELOW rr J r: (� , _ GRADE,'pIT WAS`DR YATJUE WEi.OFF . t .' CESSPOOLS (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 F:' materials of construction + ' indication of groundwater inflow (cesspool must be pumped as Part of inspection) (notemcondition�'f -' signs of hydra(�I :j ' i; rf1 :i".4 ; '1 5.;'i+,;.tztrtr: 4: . ... �t+s• . J. :r: °ri' 1} I or repairs, etc.)o soil' ulic failure,level of ponding, condition of vegetation,recommendations PRIVY: for maintenance (locate on site plan) materi construction alsof �; ; •, c•r -; dimensions depth , ,' : A: JI P of solids Comments: (note condition of soil,signs of hydraulic failure,level of � or repairs,etc.) pondin ,; i,, g,condition ofvegetatio �`'- r # i f :' ,?;recommendations for maintenance f' 7 ).: 'r:in> (7.1ie4'•, :r�(4r '.,. . ...,1� .��.i��441'• we,., '�ti(xax _ . . r , `w ✓ 7 SUBSURFACE,SEWAGE.DISP,OSAI�'SYSTEM�'INS'PECTION:FORMF-t_i +:' 5 PART B SYSTEMINFORMATION:continued SKETCH OF.-SEWAGE DISPOSAL SYSTEM.:' .,-,;: ,! include ties to at least two permanent references, landmarks or benchmarks;locate"all'-wells'•within.100'" $6(, NEWTOWN RD. rT !'tit i fiyjx..fe<+:.. ,<J +..o„ d1 �. ir, 'P' 1 't!t j!r' �.{' i`e.•"fl .�.Jt��.[is.K J..._y ... -�f iL; :... r; °r„"' -'rtl..�T?ii Ott '.''. Z.J.ts"rrr +!?l. . .i �[) i:r� i'. . ;ti',t°•+ T�. . . f'• t` � j. r ..,. r .-, is t, ._ �. _ .:i1:r i i "jtg P.;r" i i' •1••f! ;l�c. 6' ... .. ., 'r� � 4.. i.-. i,�^� i� i+, , 5'.i... . i..F . i.�4 e ;�� •.ta DEPTH-TO GROUNDWATER . .� �'. : .. .t ::t..♦ *�ii � '�.r.3 �' ;1! .lit-;'�. �°.'i ,{.rat .. �;:. ...�Cr ?i dS.�t•.•`�.�.r ..J !' r, jt.Y+t l M ( It e1 7r { r 't+ .1 r,t i .i , r; .4(t .t "`1:�• t t .S r� �t.K. .i . � iZ !�i'1.<t - p 'j�_ •Ys l..j..i. n I+. ! �u s:.,...:(,�s�{... Fix _ >116" depth to groundwater method of determination or approximation: BOTTOM OF PIT WAS DRY AT THE TIME OF THE INSPECTION. I SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM' , ' ' ? 6 PART`C w. FAILURE:CRITERIA Indicate yes, no or not determined(Y,N, or ND). Describe`liasis of dete mih4ti6fi4n4ll instanoes:1If "not determined';.explain why.not), ,; ,: e;� ,.;t ar1j..: N Backup of sewage into facility or any component as a result of an overloaded/clogged SAS ? N Discharge or ponding of effluent to the surface of the ground or surface waters? N Static liquid level in the distribution box above outlet invert? N Liquid depth in cesspool<61$ below invert or available volume< 1/2 day flow? N Required pumping 4 times or more in the last year? number of times numned 7,NONF ^, N Septic tank is metal?cracked? structurally unsound?,substantial,infiltration? substantial exfiltration?tank failure'imminent? N Is any portion of the SAS;'"ce spool or privy: 1 . . i.. ._ below the high groundwate`,elevation? N within 100 feet of a surface water supply or tributary to a surface water supply? N within a Zone I of a public well? N within 50 feet of a bordering vegetated wetland or salt marsh(cesspools and privies only,t&the SAS)? N within 50 feet of a private water supply well? N less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable;attach'copy of well water' ' analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen II SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM 7 PART D CERTIFICATION Name of Inspector: James A.Orphanos Company Name: Certified Inspection Associates Company Address: 47 Cameron Road North Falmouth,MA 02556 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check one: X I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CUR 15.303 Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature: a*u..00, Date: JUKE 23, 19 5 Original to system o r• IVERSIFIED PARTNERS 5015 SPEEDWAY BOULEVARD FT.WAYNE,INDIANA Copies to: JOSEPH GIBSON Buyer(if applicable) 33 HERITAGE DRIVE BOURNE,MA 02532 Approving Authority: BARNSTABLE HEALTH DEPT. In accordance with Title 5,this inspection is not designed to provide information to demonstrate that the system will adequately serve the use to be placed upon it by the owner. The inspection is not a guarantee or warranty of any kind. L TOWN OF 1'-1MrZNS1rAYSL(;._ BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D .- CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS ASSESSORS MAP, BLOCK AND PARCEL # hiaQ ca 7-9 9 OWNER' s NAME 56 k kfu fz's I Pie 6 ek K I W E(Z-% PART D - CERTIFICATION NAME OF INSPECTOR YV%.es A ,0 (Z '%4A A 1,LO COMPANY NAME CL--2) % F'(*D =N&-PdEC-T(0Kj COMPANY ADDRESS -4 -7 C^ tYkefZOQ 40 . 4 rALMQQ'% tA 1\A rN Q L%'S Street Town or City state ZIP COMPANY TELEPHONE ( S-OS-) T(z4 (Slz�3 FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on site sewage disposal systems . Check one: System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C FAILURE CRITERIA of this inspection form. Inspector Signatur Date One copy of this erti ication must be provided to the OWNER, the BUYER (where applicable an the BOARD OF HEALTH. If the inspection AILED, the owner or"`o'P' erator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 .. partd.doe Y TOWN OF BARNSTABLE O a .00ATION l 66 SEWAGE # r M VILLAGE 2:lag�'7oyf:lul&i ASSESSOR'S MAP &LOT 9 9 a INSTALLER'S NAME&PHONE NO. 70 S f-P W 6 6 QS B n! E6 W SEPTIC TANK CAPACITY 1 ,00o 64-6 LEACHING FACILITY: (type) c 5-d b GAL P&IalE l' (size) G X a No.OF BEDROOMS 3 ' �6 BUILDER OR OWNER J S' W 66 02J PERMIT DATE: 3� / COMPLIANCE DATE: f Y 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 bAb n f f NO. =°! Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipplic tion for Miopaal *pztem Con5truction 3pCrmit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. M14? P49t&L Owner's Name,Address and Tel.No. �fL�# af6h� 4, Assessor'sMap/Paz c�Map/Parcel g / �9 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Z-ost-pt4 GrgdoN �of Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(:i/) Other Type of Building,,,! d/6LE ?c;1jkf• No. of Persons Showers( Cafeteria( ) Other Fixtures Design Flow S 30 gallons per day. Calculated daily flow __iv® gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /'61),a Type of S.A.S. e2 <-Z)o w Description of Soil _r1h6 !X Nature of Repairs or Alterations(Answer when applicable) 14%2 S'i-31Zt 77.--I�o too 9"01t4e o Date last inspected: d Zi,f 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 b"ffi—S_Rbar9of Health. Signed Date .� Application Approved by Date Application Disapproved for the following reasons IV Permit No. Date Issued r S / No. s { _ s Fee } THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for Migpool 6pelem Construction Permit , Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. MW P�/?t�� Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /lip. /��I1,/j✓ti/ /c 1 _ Type of Building: Dwelling No.of Bedrooms .3 Y Lot Size sq.ft. Garbage Grinder(A/) Other Type of Buildingk.Sft/�LF ,,rWN. No. of Persons Showers( /) Cafeteria( ) Other Fixtures J Design Flow •.1 36 ' gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /vCL Type of S.A.S. <,2 <L4, act ' Description of Soil SVv t Nature of Repairs or Alterations(Answer when applicable) 142 ,S r Lc 'c.�.� S �E. l �Go,0 Ll t//, ., GAee�/✓ Lug s`! 41 .) 7f3-V -, Date last inspected: al! y",f Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by,thi guard of Health. Signed �--� �' Date ..? ems/ _..- Application-Approved by. �. i .► __ . Date Application Disapproved for the4ollowing reasons r Permit No. '"' Date Issued ' ' ^` P - + F THE-COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (tompliance THIS IS TO CERTIFY,that the One,e Sewage Disposal System Constructed( )Repaired( )Upgraded(V) Abandoned( )by V ,� 1 at t7/G•e P, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. A/d'J dated . Installer d K!� M ; t fold Designer A The issuance of this permit shall n c a ed as a guarantee that the s s e wwilyl�ffuncti rn as dLesigned�j /crT Date 4 Inspector !%11/= r� t !1/I/t ( 1 - ,- --------------------------------------- No. Fee ' v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'W6po.5ar *pzteru Construction Permit Permission is hereby granted to Construct(- )Repair( VSUpgrade(. _)Abandon( ) System located at- fi'�iG %v1~/Y`�w.� �D J!�"rr'df Hf r and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this -,m*t. Date: 4—F_ Approve y;- 7 TOWN r'7-'B'::TtNSTABLE LOCATION SG& WEVIOWn1 R-b • SEWAGE # VILLAGE hA AR5,10tJ Mi a-LS ASSESSOR'S MAP &LOT 28 INSTALLER'S NAME&PHONE NO. J[i«PJ . IAA 1 P For- t C A w►,►��r i 3i�A. SEPTIC TANK CAPACITY %aim 6. crt.o tJ S LEACHING FACILITY: (type) ?1 1— (size) g�^ NO.OF BEDROOMS 3 BUILDER OR OWNER DtVEI11s PtE11 PM rTMF_J9 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: t� Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) -'atr+W W,413ZZFeet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) , j�`1/ X3/?S N]N Feet Furnished by + Cen.T• ErvsP. A&&Gc-, ( 010 v q^6 4;3 d,. L077 3 0 JY 140 5 nF 0 b N" /1 o i o jGT LOT 100 w � � Sd11 R = 1558•10' r�a ��fl L = 5.55' NOTE; WMICLE TRACKS' ARE NOT VISABLE ON GROUND. RES.. z°NL: "RI, This MORTGAGE INSPECTION Pla 19- or ! FLOOD ZONl+, "C" DF I✓D REF: _5_3. - REGISTRY 0 WNER: �J1VEftS/I1F(1 ARTN� lS 11I! DATE: _S�IB.I�s --- 6UYER: �IOS�PK lJ,. JUUlNE. A� U3�S _ _ _ ._ __`_—__ PLAN REF: Zu �¢ SC E;, -;,— — I H EF EBY CERTIFY T -�{YY � _-/' F - � - -- 4 FT. "Q___ -- - ___7'HAT THE BUILDING ESN or .��f YANK ;E SUItV y SFio 'YN ON T'IjIS PLAN IS LOCATED ON THE GROUND AS �`� SHOWN AND THAT ITS POSITION DOES CONFORM �� P�L CONSULTANTS TO THE ZONING LAW SETBACK REQUIREMENTS OF THE qn8 (SUITE 1;) TOWN OF 9 Z1VSTi181_.Is_ , 3 MP-RlrnEw N IT DOIS_1VOT - - ---- _••-__ANL) THAT No, 32M a INDUSTRY ROAD LIE WITHIN IHE SPECIAL FLOOD HAZARD �o� p � MARSTONS MILLS, MA, 02648 CCo �SHO�pI� ON THE 50DUI 0015 C/QED /-l�lB.5_ 'ass,y�I`� osJ� TE ' 426-0055 I�At A. � THIS PLAN N01' MADE FROM A I STRUMENT blER T FAX. 420-555� JC Sr11zVEY. NOT TO BL USED FoR FENCES EX. 16f332 DP(� TOTAL P.0 1 • ,� F N ` �,y 1 j t ((f 4^ '7 5 LY TIE �l�... ..1 y,�.�k�')/.'•t t'"6 p��"��r,.,, ,ram;y!Y � /��'/f'.[fe+'/ i i t y i 3 { I ti y � f i Date: \ ` Q TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: BUSINESS LOCATION: C-\ S LDS M MAILINGADDRESS: Mail To: TELEPHONE NUMBER: Board of Health Town of Barnstable CONTACT PERSON: P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPE OF BUSINESS:,�OCAxLy-\ CC��-s\s_A Does your firm store any of the toxic or h rdous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antif reeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS LOCAT10 SEWAGE PERMIT NO. VILLAGE INST� L III AMOE i ADDRESS 8 U I L D E R OR �� 'oollkucv DATE PERMIT ISSUED DAT E COIN ►LIANCE ISSUED 117 Y � Alef/ N�7o�A-1 le4 Vr 'No.... FRic... .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J ..........................................OF............................................................ Appliration for Miltaiial World Tantitrurtion Prrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System 4900P 7 Location- or Lot No ............ .......... .... .. . ...................... .............................................Address ........................................... . .......................... .................................................................................................. Installer Address Type of Building Size Lot.Q?,...dy..sf.. ...Sq. feet C-Pl— Garbage Grinder (/VO U Dwelling—No. of Bedrooms............................................Expansion Attic �_l PA Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures .................................................................................................. Design Flow.............-:57-S..................gallons per person per day. Total daily flow__._........_. ....._...._..........gallons. W Septic Tank—Liquid capacity/000gallons Length................ Width..............._ Diameter__-____---__-__- Depth....._...._..... ---------- Disposal Trench—No..................... Width......0.............. Total Length.................... Total leaching area--------------_---sq. ft. Seepage Pit No--------/.......... Diameter...../JO....... Depth below inlet.....4........... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) 1 aPercolation Test ResultA, Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit._.._____.__........ Depth to ground water.__................_.__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._.._.__..........___. ............................................................................................................................................................. 0 Description of Soil........................................................................................................................................................................ --------------------------------------*-------------------------*-*,*---------*-------------------------------------*-------------------------------------------------------- ---------------- ..... .. ... ... .... ................................................................................................................. ------ .............. Na re o Repairs or Altergdons—Answer when applical . . ..... ...........A.............. .................................. .. 15 U N f R -- ------------ .......... e--—---------- ---A A reement: ®� VA) Al 2;?`� 'All- SewagJ DiWal System The undersigned agrees to install the aforedescri ed Individual m in accordance with the provisions of TL I HE 5 of the State Sanitary Co — The undersigne urtA/grees not to place the system in operation until a Certificate of Compliance has bee sue bo ie A// Signed-. ....... .. ... ... .............. .................................... A D..t..... Application Approved By......_,4 .. . ... ........ ..................... ..................... Date Application Disapproved for the following reasons:............................................................................I.................................... ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued ....................................................... Date No.-- ................... ••• - 9---- 4HE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --'---..... ...:..................OF......................................................................................... Appliration for Uhipos al Works Toaastrurtioat Prrutit Application is pheer'�eby made for a Permit tjo Construct ( ) or Repair ( ) an Individual Sewage Disposal System Location-Ad op or Lot No. ...: �L ........ 1....................-.......... .......... ------------------------------•• ------------................................-- l'�C. /Ofi�l�✓ .... 7...!__�.........................•. .....................................------.Address......... ......................... Installer Address ��a� of uilding U TypeDwelling—No. of Bedrooms........... ........................Expansion Attic ( ) Size Lot.E .rage G ri ge deq.(/Va '14 Other—T e of Building No. of persons............................ Showers — Cafeteria at Other fixtures .................................. n Flow Design ............. .......... gallons p p per y ............ . __ W allonserersoner day. Total daily flow .............gallons. 1:4 '` Septic Tank—Liquid capacity !..gallons Length................ Width._.............. Diameter................ Depth................ Disposal Trench—N .-----•-. _-_-- Width------ ------------ Total Length..... __....____ Total leaching area....................sq. ft. jj Seepage Pit No--------�...__---- Diameter...../0..... Depth below inlet.....A ....._.... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test ResultsX Performed by.......................................................................... Date........................................ ,.a Test Pit No. 1----------------minutes.per inch Depth of Test Pit.................... Depth to ground water........................ (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-••-------------------------•-•---•-----------------------•---....-----...--------•---------------.......................................................... 0 Description of Soil......................................................................................................................................................................... W ......................................................••••-•------'---------............._._................... a */• ...' _ ------- •-------•----•- �• f UNature of Repairs or Alter tions—Answer when applicab ..._ __I-_-_`-------------- .........10( Agreement: Ile w e1,& 1?1-0* 6!� �F� �_ � �iP!�� i�/��/��Arl 4, The undersigned agrees to install the aforedescribed Individual ewaget Di s sal System in accordance with the provisions of TITLZ 5 of the State Sanitary Co —The undersignedjurt grees not to place the system in operation until a Certificate of Compliance has bee ' sue b e f 1 Date Application Approved BY•••--`.... --- ------------------•------ - `s / Date Application Disapproved for the following reasons-..................................... ........................................................................... -----•--•--•-••••.............•---•--••-••......•••-••••••----------•---•--•-•---•--.......•••-----•••--•--•....'--'---•--'---••--'-••'••--••----••-•-•--•--•'-••-•---------'----'------•---•-------•--- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF................ .............................................................. (9rdifiratr of TootpliFattrr THIS IS TO RTIF , That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by............. .....................................•-------•-•-------------..........:_......-----------------------------••-----•--•-......._.......... Installer has been installed in accordance with the provisions of TITLE 5 of.,The State Sanitary Code as described in the application for Disposal Works Construction Permit No..___._...'Z'-d;r.!g............. dated---------------------........................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED q5 A GUARANTEE THAT THE SYSTEM W14L �UNCTION SATISFACTORY. ff DATE.•.•�� !7 - Inspector------..... .............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................OF..................................................................................... No...................... FEE........................ Disposal Works Toato#ra ion antic Permission is hereby granted d �... .✓.�-.------------••-----------------••--..._...-•------•-----'--------.............................. to Construct ( ) or Repair' ( an Individual Sewage Disposal System at No.......... ,s'6 ... . - ?j,. <...............••-•--'-----------------•---------------------------....... ..................................................... .....••-•_.... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ---------------------••--------------------•----•- -.- Board of Health DATE .................... � /.r ?t.. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS L L ATI.ON 5E WACtE PERMIT U-.O. a a _ IWA WSTALLER 5 U&ME t /,DDRESS BUILDER 'S Q &MF- ADDRF-'55 DATE PERM17 ISSUED - - - D ATE CONIPLI &MCE ISSUED : - - - Cog R� p v use r . it ^M r � 3 d . 3