HomeMy WebLinkAbout0155 WOODSIDE ROAD - Health 155 WOODSIDE DRIVE, MARST.MILLS
A=127.029
-
1,
i.
ti
I
i
J �i C -cl /YI L Tom- /q/w
V ry t
�i/i�"'r�s" . r/7a-� �X�'✓J�� /Ci�L L�J/¢J' n/'c�1(cy".v�j� ��✓�//� °VGA/- G�4� !�'�..� /'t /7�� G�
NC�
� IJ
;#0?
Rem veet �JU,jJfGr�
IfIAIA
j1) N I;k
V4�
IjA
Al C Xi0
L„.,,=6} -. a :.='t.4 .Y 50
COMMONWEA :rH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS
DEPARTMENT OF E$NIRONIVIENTAL PROTECTION
ONE WINTER STREL'T,BOSTON MA 02108 4819i 292.5500
TRIYV;r;:OU
Sscretsry
ARG,BO PAV,: CELLUCCI 'D!AAIID 11.ST,a,UHS
Governor. Colaziasaoner
1,VOM1RFACE SEWAGE MPOSAL SY TW INSPECTION FORM
TART A
C61II>pICATl001
c��" Q Haww of Oarrssr �e IS
NsMR/Adlioss: SJ WQZ9 j GCS l
S �.S LIS Address of aww :_ j p
OsAs at lrrspasafarl:
Nun*R Inapssstan:l4lsa�oia�o� L[J
1 ant as 01FP d sgassre in1Y!elor pWPAW t to Section MUD of mille 5(310 elm 15.0011)
caatep.,i►Narrs: dr �n✓r r< ( c cf cprt$
ISa■rIG Addysss: jbILnnti Oa flrl f
T&Isphoeos IlsenlMr: .S"D�3 f3 S--
tCATIg1�TA7®A!Q
I certify that I that personally Inspected-Me sawap*disposal system at this address and that the Information reported below Is true,accuieto
and oornpiote ss of the time of inspsction. The inspection was performed based on my training and expsrienne in the proper function and
maintenance o1'on-site&*wage disposal aystems. The system:
x Posses
-_ Condhionally►mass
Needs Futon Eiraluation Sy the Local Approving Authority
FrAs
linspeotwe SiSnahere: .:A& ` oses:
Th*gystem Inspector shall subm t a copy of this Inspection report to the Approving Authority 116oard of Health or DEPlwtthln thirve 13016sys of
completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or grester,the Inspector and the system ovener
shall submit the report to the approprists regional office of the Deportn+ent of Environmental hotection. The original should be ssrlt to thU
systern owner Ind copies sent to the buyer,if applicable, and the approving authodty.
NOTES AND COMMENTS
.AO
ti9o` Ltd
�\
�0TP2 moo
�`ocn�A O
C) r R►
�r to
4.
revised 9/2/9,�.. tripler1t
w
t
t0 hinIed an'RaycNd repfr a
SI1sSUnFACE UWAGE MMSAL sysirm wepsc i FOnMI
PANT A
/�-5 n�y C61 tTW"TIM IowU use
�� FboparityAddnm: )S LJ� itie 1CiX
on M.: ?p 6y 4er.e5
StlsMsll."TM Stammmtr: c hoob A, 111, C, dw D;
A. IVS I MSsss:
_ I hove not found any Information which indicates that any of the fallure conditions described it 310 CMPI 15.303 exist. Any MUM
Cowie not ovaiumed arc indlemed below.
contmm:.
B. sYSTM SLY►Assam:
_ 0ns or"We eystarel componante as described M the"Conditional Peace"socti cod to be ratgaced or repaired. TM system,upon
..._ cornpirtion of the replacement jrr repair,as approved by the Board of He IN peas.
ktdicste yes,no,at not determined IY,K or NO). Oescrtbe bests of detonmin In o0 instances. If"not determined", expie}n why not.
The septic tank is mrlal, unless the owner or operator provided the system lnep4vtor with a Copy of a Cnrtifk:ats of
Compliance(attsehod)indicating drat OW(anal;was ed within twenty 4201 Yearn prior to the date of On inapoctiorr of
the septic to*,wheowr or not metal, is crooked, ucturany unsound,o mwe substtsntial Infiltration or avrOvellon. or oank
failure Is imminent. ?he system will.pees inspo on if the existing septic tank is replaced with a Complying sop.tic tank so
*Waved by the Board of Medtfr.
$swage backup or breakout or hi static water level observed In the distribution box is due to broken or obstructsii Ova($)
or due to a broken,e�rttled Iw von distribution box. The system will pass Inspection if(with approval of the Board of
Heald 1.
book e)are replaced
al on is rornoved
ution box is levelled or replaced
The system ro ad pumping more then four times a year due to broken or obstruetad Plpe(a). The system wiVl Page
impeetion if Ith approval of the Sawd of Nealtir):
broken pipe($)are replaced
r
e'sotruedon Is removed
revised 9/2/98 fafr2of11
SRIBSUIIFACE SEWAGE CapOSAL SYST81i MPE RO CTN FORM
PART A
CERTIFICATION Iserrl %"
Pregert V Ad*esa:, S S (POOSS l ci4-
OWM :; ?"Q1C 12
Dols MI Rnapw I3 i,I +c
C. MAITHER EVALUAT1N10 E MOUM)BY THE BOARD OF HEALTH:
CwW.Jans exist which require fuller evaluation by the Board of Hedth in order to determine 11 system is fegkp to prelt"I ow
pub&,hum,safety and the en%fronnwent.
I l SYIa'11iMI WILL pASB LWJMB gN)ARD OF HMT14 DETROMES Bel AC'CORDAN 310 CUR 16.SOS t1Nb1 TiHA,T'Ir"E,tYlGTlil)il
E NOT FUmCTWURA i IN A IIIAINNEA WHICH WILL PROTECT THE PtJIUC AND SAMMY AND THE IBNVM MOEINT:
_ Cesspool or privy Is within 50 feet of surface WSW
Cesspool or privy Is within 60 feat of s bordarung veget rredend or a salt marsh.
2) SYSTEM WILL FAIL UNLESB TWIE OF HEALTH tANO pUBLiC WATER SUPPLER,F ANY$DETERUNES THAT IHE SYSTIEM IS
FUN IN)II1010 N A MANNER T PRO TEM THE FLUX HEALTH AND SAFETY AND THE EIVMIOII UM:
The system has a a c tank and sob absorption system(SAS)end the SAS Is within 100 foot of a surface welar Supply or
tributary to a eerrfa •water supply.
The system has saptic tank and soil absorption system arW the SAS is within a Zone I of a public water SuIP"y ws#.
The syeto v a septic tank and soil absorption system and the SAS Is within SO feet of a private water supply wall.
Tha system a a septic tank and so l absorption system and the SAS Is lass then ICO feet bet 50 feet or more from a
private w r supply%VON,unless swag water analysis for cegfoi bacteria and volatile organic compounds indicates fish the
well Is from pogudon from that facility and the presence of ammonia nitrogen and nitrats nitrogen Is equal to or Iess
than Method used to determine distance _lapprodma IGn not a NIM.
�1 OTHER
re•.dsed 9/2/98
Togs)sf lI
SLNb LMFACE SVWAaE DISPOSAL SYSTQO NSPIECTION FORM
PART A
CER I1PICATION IoanMrastll
PeapeAy A�ae.. , r� (�-�ocl�s icy Q.U+
el:bsipeerNeil:text
'l 31
Dent �
D. Vfsl>r m Im":
You Mist indiseas ehher"Yoe"or"No" its each of the fdiowMO:
I haws determined that one or mMne of the following failure conditions*dot as described in 310 CMR 15.303, The basis thaw this
�. deterntinadcn is identified below. The Soerd of Health should be contacted to determine what will be necessary to oorrecr,the fallurn.
Yes No
y !lockup of sewage into fsdifty or system component due to an overloaded or clog SAS or cesspool.
T _ Discharge or ponding e4 effluent to the surface of the ground or surface w s due 0 an Ovsrbsded or clogged&AS or
cesspool.
State liquid level In this distribution boa above outlet invert due an overloaded or wagged SAS or cesspool.
Liquid depth In ce"P00 Is fees than$-below invert or ebb volume is less than '1l2 day flow.
_ Required purinping more then 4 times In the last or WT duo to clogged or obstructed pipets)•
Number of times purnfted_;
Any pardon of the Safi Absorption S am,Cesspool or privy is below to high groundwater elevation.
Any portion of a comeal or Is within 100 feet of a surface water supply or altutsfy to a surface water supply.
Any portion Of s Castel or privy is within a Zone I of a public WON.
_ ;Any
portion Of a esl►od or privy Is within 50 feet of a pelvste water suPPlY wall.
_ pOAi of a coalsool o►privy is lose•then 100 lest but greater than 50 feet horna private water suppiYden N wi+ih is*p a water quality,analysis. If the well hoer been anatyted to be acceptable,attach copy of WON water enislysM few,
becteris, volsRNs organic compounds,ammonia nitrogen and nitrate nitrogen.
E lAIIOE S MM l FAS.S:
You nsast iewllt eta ailhsr"Yes" or"Noy Ob eech of addition to the eriterie ebo�gss''�
The mowing Criteria apply, g Y�
The isysftm serves a foa ty with a design flow of 10,000 Spill rector(Large System)and the system Is a signific'mut t:hrsat tt'Public
health and safety and the envfronmtent because one or rnor the fallowing eonditiens esien:
Ya Ne �
tha system is within'100 fee of a drinking water supply
_ the system is within 200 of a Mbutery to a surface drinkino water supply
"system Is locate a nitrogen senslthro awes(Interim Wellhead Protection Area:fWPA1 er a mapped Iona N of a Rublic
WOW supply won
The owner Of apOWOr Of any s systjtn+shall upgrade the system In accordance with 310 CMR 16.304(2). Please consult the IOeel reoi,2na1
office:sf tiro Department for Into r..%all
revised 9/2/98 PW4of 11
IiUSIRMACE SMAOE DISPOSAL SVSTIW MISPECTION FORM
PART•
CHECKLWT
ftwotlo
®wstar: y eh.s S
Case of,rspaoIs.
Check IV the following hew been dons:tier must Indicate ehher"Xes`at"No" as to each of the following:
rya No
�. Pumping Information woe provided by the owner,occupant. or Board of Msatth.
None of tha system caii%wients have bean pumped for at least two weeks and the system has bean°recelvhg rrs!mnel flaw
rates during that perioc!, Large volumes of water have not been Introduced into the s fstam recently Of as parr:01'thts
As plans have been obtained and oxonNned. Nat*if they ore not available with h IA.
The facility or dwelling was Inspected for air*of sewep back-up.
r The system aloes not receive non-sanhtary or frJustrial waste flow.
The site was Voloaeted for signs of breakout.
All system components,excluding the Sop Absorption System,have been located on the site.
The septic tank manholse were uncovered,opened.and the interior of the septic tank was Inspected for cone t wi of baftlen
or tees,material of construction,dimensions,depth of liquid.depth of sludge.depth of scum.
The sis*and kscation wr the Sop Absorption System an the shay hoe been determined tesed on:
f t Existing information. Fc1r example, Plan at B.O.M.
Detwmnwd in the field(if any of this failure orlteris related to Fart C is at issue,approximation of distance is unac:ceptabit)
1'g.3C+2(3)4b1i
The facility ow (and occupants,if different from ownw)were provided with information on the proper emsinterence 01'
Subsiurtace Disposal Swatems.
revised 9/2/98 Polls 9of11
i
• SUiSSUtRFACE SEWAGE DISPOSAL SYSTEM MPECTION FORM
PART C
n SYSTMI fAFORMATION
LkJ&
DiM of ksapesRlaAl! o
FLOW CO%Vffl o
ilew: t p.d.
Nuombor of bo&soens(dQsl�r+ Number of bedrooms isetusq:&
Tool DUIGN floof dri
*Anbo of'oufrerrt reeidents.
Garbows Grinds.Ives or no)'
Loundn Isoperees systoml Iyos or no):_Ap If yes, separate Inspection required
Laundry aysts o iRpsoas !�s a not
orad Soos we(yes a no):N
Water neter roodlnos.If ev lable(lost two year's weals(ppd):
Swnp Pwrtp Iwo w ra):
Last do*of eaxepaney: `V C'f
Typo of esnb6shment:
Del ftw: and I $esed on 16.203)
Sods of desip fbwM.--
Grasse-taep presents lyess at no)_
Medustrfad Wesa 04ofafrr8 Tank pros :lyou or not
Non-serdtery wftfbs disch$rW This I system: (yes or no),,,,,
Wow rwtor rsarsines.If aveR e:
Leat dilte of occuPincy:
011` I::IDescrbell)
'.m ewe of GlY.
GEf11EJ1Al SffF0116AATItON
Pull if3 RMWA and source of W,r a yn
: r
tratem pumped as Part of inspection:(yes or 11,140 �
If yes, veiurno pumped: ,_p6ons
Rol, for Purnpirp:
TYPE OF SYSTM
$am tw*de6MM rsop 468orption system
—; swv*escaped
Ovwftw coespoof
Shared system(yes or no) (if yes,anal previous inspection ro:ords.If any)
i!A Toehrwiopy ote.Attach oopy of up to date opsratlon end meintonsnrs contract
TW 1'ank Copy of DE!'Approval
APPROXUATE.j%QE of et)sornporrerrts,d1jo instellod(if known)and source of)aforMWO":_„ Q� eel> _-- --_
Seww edoxe 6*ucted when arrhrin0 at the site:(yes or real,6
ti
revieted Si/2198 I'epsorlt
SUISSURFACeE SEWAGE DISPOSAL SYSTEM NSPECTICIN FORM
PART C
SYSTEM rrFaarAnoa(atnikausdl
Ps
0 of a.Yo"609 1 e i5
FP.saT.�• '� `�p0
wRamG Sewer: �`
(locate an sets Toler►!
a
Depth below gnrdt:I
bfltterial of corammoven:_cast;ron ,o PVC_other iexpialrr)
Distarren hom�prate water supply well or suetlon line �.--
Cormnsats llaorut don of joints,venting. eAdencs of leakage,*tc.i
SiSf10•TAIK•
ilooats M sift plan)
Depth below gruds:14
ltiletsriai of construction:1concrsts_m rW_Rbergiess _Polyethylene,_oche►{explain?
if tank iui metal,Nat age_ Is age aonfbrned by Cartillcete of Compliance lYss/Noi —
Dirrarrsiam:
Sludge depth:_
Distar►os f►am tap of to bottom of outlet too or beHle:-SU.
Scum OwAnese:_I- _ r
Oiaamos from tap xi scum to top of outlet tes or battle:S_ a
Dlstancs from b;mtm of scum to bottom of outlet to er baffler
low di ronslons were datennMrd:
�"Comments:
freeornmendetlan7 fer pumping.eonftn a and outlet tees or bales, deg of Squid avel I rely'o :o outlet i veR, tructurN:intagritt,
evtdonee of Isakne, .1
f91�/ffpB T�
One"on sine plan),
Opth below g►eft:_
Idstarial of oonsituction:_concrete,_motel_Fiberglass _„Polyathylene_ eaplainl
IDN is lane:_
Scum fIM kness:—
Dletence from top of scum to top of outlet tee or baffle:
Distant*from ktteen of scum to bottom of outlet too or b s:_„__
Dese of list pum:o ng:
Carrmemm:
(recommindNieri for pumping,eondltlen of ins and outlet tees or beffles,depth of liquid level in rotation to outl*t Invert,structural iintegrity.
come to of leakage.aft.) —•—
revised 9/2/98 Parlous
SLIGSURFACE SEWAGE DISPOSAL SYSTEM NSPEC ON FORM
PART C
SYSTEM SIWOIIMATION IaertgrareM
d �(oC>
TIGHT OR HOI.IIMIIG TANK. (Tank niust be pumped prior to,or at time of,Inspectioni
(iecate an tit plan)
Depth below @red*-.
Materki of construction:_concrete_m,rtal—Flbaglsss olyethylene_ofowtexplaln)
Dimenalons:_
Capedi r:—gslbru
Design fbw:_gallons/day
Alamo Ivesent_
Alarm IewW:_ Alarm in king rrcde►:Yes_ No_
Date all prevleus pumping:
Comminute:
(condlton of Iniat tee, c Zion of alarm sod fleet switches,etc.)
OWMINUT" BOX
(locate on ate plan)
Oepth of Ilpuid level above outlet invert:_
Comm+aMs:
`note i(hval end 6seri6utlon Is equal,evitlence of solids carjyavea*gvl�ge of Irrekago o{out of bo:c, etc.! �
Ck
h o
PUNIP CIIAM11161:_.
(loos"on eke pant
Pumps in working order.lye$or Nol_,_.
Ahrens in working order(Yes or No)
CemnmMe: _
(note eondldon of pump chember,eon of pumps and appurtenances,etc.) — -----_--`—
revised 9/2/98 Ptrtof11
sulISILMACE SEWAGE DISPOSAL MysTIN INSPECTION FORM
PART C
srsTBA RAVORMiAT10N teotttleandl
49
Ornw: fig Jp i e +S
Dab ot1!l- 0 d.iv 1 0 d
so4.tvsaw�eooM s�Ter aAs�:g,..
(locate en ails plan,if possible;excavation net tsquired, location may be approximated by non-intrueive methods)
If not lamed,explain:
Tye. Is a! pin number:
oschkM ohwttben,nu :a
load*q galleries,number.,
Issehl►o"nehos,number.bngth:
lose"1Aaids,number,dM»nskmis:
overflew aeupooi,rtmndw:—
Ahmrndwe system:
Nano of Tsohnology:
Into 39+u3ltMon of , signs of hydraulic fwfu ,level pending, demo soil, eon*uon of vs statiory etc.)
r�s r v r�5_5�'Zbl rw,�
pocats On aft plans
Number and eonfigmillon:
N01th-tcao of N*id to Not invert:
apth of solids layer:
--0spsh of scam UrM:
Ditttaoll eats of anspool:
matariafl of cenavustion:
indieadou of vwsndwater:_
inflow leesepeal must be pu ad as part of Inspection) ---------
Conematos:
(nets ceadition of sop gns of hydmAc falklm,level of porW tg. condition of vegstation, at-..)(locate an sfa plans
Metwislis of aorotruatlon: pirnertalaw:
Depth of solids,_��
Commews.
Inns cu m4 Rion of loll,algae hydnulfe faihrra,level of pending, condition of veflotaton. eta.)
rev:.sed 9/2/98 Ps�ssof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM PW ECTIM FOAM
PART C
SYSTEM MF0RMATm"I090An6"
Owmr:�1 eti 6S
Deb of d 3 Gov
SKETOI OF SINAGE DSPOSAL SYSTEM:
indads tles to at lest two pail rwnt referarlce Iandnwks or benchmarks
IossnLs sp woos within 100'ILoew*where public water supply comas Iris house)
1 \
g►
I
o�
revised . 9/2/98 Per10atis
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM KSPECTION FORM
PART C
SYSTEM NW40RMATIOM(Omokwsdl
o.�rer Pfo t eau
Data of IN . 1 -3( 00
NRCS Report name —
Sall Type,_,
TyOcal depth to groundwater
USGS eat.webeb visited
Obaervatiat Wets shocked
Groundwstor depth: Shallow_ —Moderab_
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimator Depth to Groundwater I Feet
ploesa indicate sM the nwOm s used to determine High Groundwater Ebv*don:
Ob Wnad Prom Doolp Plans on record
Obsorved:l:te(Abutdnp proper",observation hole, ►asoment sump etc.l
Determined ham local conditions
Chucked vrlth local Soerd cf health
Checked FEMA Maps
Chocked pumvinp records
Checked krcal esoevetors,instele►s
Used USGS Deb
Desedimp hdw y3u es%Wshod tM Nigh Gnwndweter Elevation. (So be completed)
t
rev:isied 5o/2/98 tretrtttrtt
08-12-1998 02:23PM CENT DST FIREDEPT 5087902385 P.02
1 ArIawe aNNuwu.nr w mu-ni rice wepctrunenit.. o
Fue.Department retains original application and issues duplicate as Permit.
t'4v�wi
s�ian�Grnenta �iixe��xvioea — off �
APPLICATION and PERMIT Few, 1000
for storage tank remcval and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 14E. Section 38A, 527 CMR 9.00, application is hereby made by: , ::',
7Tank
FOwner
John PautienisName(please print) X
Address 155 Woodside Drive, Marstons Mills "`� �°�`"�
''
Snesr C+b &hm rip
1
Company Name Advanced Environmental Advanced Environmental
P Y Co.or Individual
PrM PnM
Address ..P.O. Box 472, S. Dennis, MA Address
Print
Signature(if applyi :tr:ermit Signature(if applying fcr permit) I
i
OV
2rt�ec er r IFCI Certified = t Ci=# :Other
TankLoaatiori 155 Woodside Drive, Marstons Mills, MA
i
Sreet AOMSS GY O
Tank Capacity(gallcns: 500 Substance Last Storms #2 Fuel Oil
Tank Dimensions(dip_-c-ze x length)
v
Remarks: L � A-Pmo r 5 0E >✓n�l
C &-log
Firm transporting were State Environmental State Lic. # MV5083856100
Hazardous waste mar f,,--- E.P.A.# _
Approved tank dispcsa;ysrd J.G. Grant Tank yard# 03501
I
Type of inert has Tank yard address Readville
Centerville 01920
City or Town FDID# Permit#
August ,l2, 1998 August 26, 1598
Date of issue Date of expiration
Dig safe approval number- 9832076 3hiDin S Tou i .8d0-322-4844
Signature/Title of Office panting permit
:2 L—M 4 9
After removal(s)send Frrr. ='?-290A signed by Local Fire Dept. to UST Regulatory Complia-=-Una, One Ashburton Place,
Room 1310, Boston, MA 2-08-1618,
FP•292(mvised 91A61
TOTAL P.02
i ;�
��
, j
—r-_-�kj—7
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel 6_.) 9 F� , 3= . ` ,r' � i�y3LE Permit#
Health Division4 4 rtoP a,m c. i Date Issued 2
C.
Conservation Division ` n� FEB _ F ee � 7
Tax Collector -,9-pi
Treasurer_ S�' - �+/ ��/�/ r r µ M �` +��i SEPTIC SYSTEM MUST BE
INSTALLED IN COMPLIANCE
Planning Dept.t. W=TITLE S ®rrl
Date Definitive P
E"ON tTAL CODE AND
t ve Ian Approved b Planning Board
pp Y 9
TOWN REGULATIONS
Historic-OKH Preservation/Hyannis
Project Street Address �S S 1 f' Ya
Village l c-7- XQ,4
Owner Au, Address
Telephoned
Permit Request
IV
Square feet: 1st floor: existing e,7J proposed 2nd floor: existing Id 471Zi proposed ----Total new ..-------
Valuation A_ 16 Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 4,--.'�wo Family ❑ Multi-Family(#units)
Age of Existing Structure y, Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: ❑ Full ❑Crawl ;;Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area .ft
(sq )
Number of Baths: Full: existing 13 new Half: existing new
Number of Bedrooms: existing new
Total Room Count (not including baths):��existing knew First Floor Room Count
Heat Type and Fuel: Gs Oil ❑ Electric ❑Other
i Central Air: ❑Yes :�o Existing
Fireplaces:
p t g New Existing wood/coal stove: ❑Yes ❑ No
Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn: ❑existing ❑new size
Attached garage: existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
/ BUILDER INFORMATION
p G
Name i �` e, )C)C '* . Telephone Number do 6
Address o2 z f c Z11 License#
�r Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTINGG/FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE r DATE
TOWN Or BARNSTABLEG
rA
1
u UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS V�
�\r
ASSESSORS MAP N0. 7 PARCEL N0. o ' 3 55
ADDRESS: /�.� LcJoods.'r�e_ ,�'OC2 ce- VILLAGE %7i //s
NAME!_..�.. .�.c2 f7.
nJ.._:. . /.Aa
CONTACT PERSON �OA PHONE NUMBER 44 e / 6 a2.
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL. AGE: TYPE: LEAK
OR CHEMICAL:, DETECTION
Behr V el h G745e- Z 0 0. 1--`---ss�='°"
DATE OF PURCHASE OF. EACH: 1. 2. 3. 4. 5.
DATE OF- FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD.
I
�a
III �
✓ �aR�S
ri
/ , TOWN OF B TABLE
SEWAGE #
VILLAGE 'l Ct r6fD kS I" L c I LS 1�-
ASSESSOR'S MAP &LOT 1✓�7 b Pei
INSTALLER'S NAME&PHONE NO. MI,C t",L \ 1. 0416 SIS5 7 6 68
SEPTIC TANK CAPACITY Li ot �C,f
1 /
LEACHING FACILITY: (type) (size) �t�bo Sc,l
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE: Zt?�1O
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
FuriLshed by
I
iti i
S � ,�,.
d
l , r� �` ..
�- . .� ��
. , � � ,
,�,
�� ���_r .
n, .�
r%:
���
�� ^
���� � 2�0
TOWN OF BARNSTABLE
LOCATION / V,1vc C t,We r'c( SEWAGE # 0 3/UU
VILLAGE_. IN- 6v.MJ,4Ljf ASSESSOR'S MAP & LOT 0Z9
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY M/00 6
LEACHING FACILITY: (type) %� lava (� (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within.200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
i ..
�� ,
6�
. 8''
26�
�.�.r
�nlu�r 2��'I G'��'�I'