HomeMy WebLinkAbout2481 ROUTE 149 - Health 2481 Route 149
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No. 4210 1/3 BLU
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BOARD OF HEALTH
TOWN OF BARNSTABLE
;(pplicationArlVell Con9truct ion Permit
e�
on r ct ' / ter or Repair an individual Well at:
App 'ca ' i here y ade.for a permit t C st u (1 , ), p ( )
Location — A dress �� Assessors Map and Parcel
Owner Address
)0� ------
Installer — Driller Address
Type of Building
Dwelling—r--� �`". --------
Other - Type of Building--- --------- No. of Pe//rsons------------------------------
eq
Type of Well � 2 -- -- — Capacity-----GL — — --
Purpose of Well--- --- —
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Pr ection egulation — The undersigned further agrees not to
place the well in operation u a C ifi a .of C e een issued by the Board of Health. s
igne — — --- -- — �— r6
dat
Application Approved y -- —---------—— ---�=�-
date
Application Disapproved for the following reasons: ------- - - —— - ---- —--
----------- -- ------- ------------------- ----
yy — date
_/ v
Permit No. �`� � `5`� � Issued---------1------ --"6 � -----------
date
i
BOARD OF HEALTH
TOWN OF BARNSTAB LE
Certificate Of Compliance n
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired
by------ ------------------- - Installer
at- — -- ----- --— -- -------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. --------------Dated----- -THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----- — - -- Inspector--------------------------- - ------—---
No. ��`4_-`O� isFee----- --- "----- ----
-
BOARD OF HEALTH
TOWN.. OF BARNSTABLE
y .
' Zpp[icationforVeil Con0tructionVermit
an individual Well
fora erml,t t Construct //), �terl
), or Re au ( )
App1 c t t here���y ade p ( P
Locatibn Address Assessors Map and Parcel
Owner Address
: --- --
Installer — Driller Address
Type of Building
Dwelling- ---=� = � ---
Other - Type of Building
/----------------- No. of Persons_
Type T e of Well d--—--- Capacity
YP Y-----
Purpose of Well --- -
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protectio�_Regulation - The undersigned further agrees not to
place the well in operation until a Ce ifica a of Co pia ee `a'been issued by the Board of Health.
igne
i date l
Application Approved By —- --—-— 5 " y
date
Application Disapproved for the following reasons: ----- -- --- --- —
date
Permit No. V3 D-00`4 ---C t4 5 - -- Issued----- -�-
date ----—
BOARD OF HEALTH
._...-, TOW N OF BARNSTABLE
Certificate ®f COMP iance �
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), oroRep ed ( ) ;3
--------- - - r s rn
ys------- ------- Installer
at- -- ------------ -- - - ------ ------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. ---------------Dated---- -------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY,--
DATE=---- --- — - -- Inspector---------- ------- ----
BOARD OF HEALTH
TOWN OF BARNSTABLE
Yell construct ion Permit
No. �'` "�` OYOq �p, "MQ COAv1U'Y1 Fee
No.
Permission is hereby granted - ---- --- ---------------
to Construct ), Alter ZV-4,,-or Repair ( ) an Individual Well at: lioozQ,rr� _
Street ��
as shown on the application for a Well Construction Permit \
No.- Dated -- -- --------------------
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®15 I 0 Board of Health
DATE—� -- —
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LOCATION SEWAGE PERMIT NO.
6m,etlr,7c,
VILLAGE
INST ER'S NAME j AQDRESS .-
• I
S U I L D E R OR OWNER
DATE PERMIT ISSUED g � _
DATE. COMPLIANCE 1SSUED V5
No..a�.. 7`Sro �� Fzs.....f. .._
THE C/OMMONWEALTH OF MASSACHUSETTS
. BOARD 9F HEALTH
........ ........OF......
1
Apphratiun for Diupuutti Works (funotn u#iun Vamit
Application is hereby made for a Permit to Construct ( _ ) or Repair JIC,) an Individual Sewage Disposal
Syst at:
-S✓r----------------- .....:�/0 1/ a�11.,0••----....... ------
Location-Address or Lot No. ..
. ... ........................................�a ..... ..............................................
er ..........................Address
......- ..............................................
---------------
14 Installer Address
Type of Building,, Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( )
p4 Other—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( )
Q' Other fixtures ..........•-•--••-•-----•---•--- .
W
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1.4 Percolation Test Results Performed by....•...................................................................... Date........................................
a
,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Li, Test Pit No. 2................minutes per inch
�Dep h of Test Pit.................... Depth to ground water........................
94
O
Descriptionof Soil---••-.._ ..... :----•-••--•-------------------•-•--------....--•-.-•-•. ----......----.-----....
x _
W ......................................................................................................................
U Nature of Repairs or Alterations Answer when applicable__...... .....__._� �.._....___S/�f.... . �.?V.......__.
• -----------•................•••-•-......._.._•----.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of iITLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ssued by t e/bod of th.Signed
Date
ApplicationApproved By.................................. .............................................................. ........................................
Date
Application Disapproved for the following reasons--------------••----•----•------------------------------•--------------------••-------------•---•------....-----
-----------------------------
---------------------
----------------------
---------------------------------
...... -----------------
•-------------------
..----------
•-------------------
Date
PermitNo....................................................... Issued.................................................
Date
Fimis
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. .. /dfJ.........-.OF.......`.`. .Jrf/�1.F�t/` �.,
... ................................................................
Appliration'flax Dispnsttl Works Tons rur#ion rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: I I
...»/: ................................................'.,.- ------- 1 `= ..-.--•..f---•- ---..''...�.....�•................................................................P................. ......_.
f Location-Address or Lot No.
! / r -- .
V Owner• Address
r �'l /
Installer Address
Type of Building,, Size Lot............................Sq. feet
U Dwelling--'No. of Bedrooms................. ._____..__.__..__..Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type T e of Building _-_.... No. of ersons____________________________ Showers
0.1 YP g -----------•----•-•-• P ( ) — Cafeteria. ( )
0.1 Other fixtures ...............................................
W.
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.....-.......... Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................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........................
pG .........................-.............................................................................---•--•-••-•-•••---•••-•••-------•-•--••••-..._...•••--
Descriptionof Soil..................-•=--•---•---'_._.......••-•-•••••-••-•-•••-•-•-••..........:..•-•---••------....--•----..........-•-•------------------................•---•----•_..
W -----------------------------------------------------------------------------•-----------•-........•----•...--•------------------------•----•••-•------------........._..............-----••---•---••_..
U Nature of Repairs or Alterations—Answer when applicable___________________________________________________________s................................r
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of TIT11 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed................:. ............................................................... ..........................»....
Date
ApplicationApproved By.................................................................................................. ..--•-•••------------------..._.........
Date
Application Disapproved for the following reasons-------------•------•-----........-------...-•---------..._.....-------------•-------------------••........»»»
--•.......................................................•--...._-_-_-•----------.__-_--•-----------------••••••--•...•-•••--•------------------------- -----------------
Date
Permit No...................................................__.. Issued.................................
..----•---......_....»
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.........-..... .......'...........................�..........................
Tntif rate of Tontpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by, ..........»..--..----•-•`----=•=•f .... ' ::.._.�..- =- - ................• ..---- -»..-•
..... .....
Installer
r ,-,
at.........':::. -- ----•-•...•-=-•'•--••»------------------•-•-•---•-•-
has been installed iri accordance with the provisions of TITLE 5 of Th State Sanitary Code as described in the
application for Disposal Works Construction Permit No........�5'�7�� -.__.... dated...... .-_'LI— .
.... ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUED AS A GUARANTEE THAT THE
,SYSTEM WILL FUNCTION SATISFACTORY.
400
DATE... ....�.._.�'� -gam Inspector....
THE COMMONWEALTH OF MASSA SETTS
/- BOARD OF HEALTH
.....OF.0... ..................
No... ... ..... .
f o r ion r wn Pernt�
� 1 ✓ ,
Permission is hereby granted......_. ` ! ... ........................ ..............__..
ao.,t Constru ( or.Repair ( an Individual Sera Dispo ,Sy �m
' at No.-- P%-4rl_�_2 ..---• . ? '... ' .....__..__ �--................ '��e ..--.... .
Street ,�,,�+
as shown on t e application for Disposal Works Construction Permit No.......... ......... Dated........ •.'�--'..C.-?--__.
DATE. f / `� 'g' ` ..... oard of Health
4
FORM I2551A. M. SULKIN, INC., BOSTON - .,t�
t r n
r
P TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: Mail To:
BUSINESS LOCATION: 2 S/ L Board of Health
Town of Barnstable
MAILING ADDRESS: V7? - P.O. Box 534
TELEPHONE NUMBER: — Hyannis, MA 02601
CONTACT PERSON: C, ca
EMERGENCY CONTACT TELEPHONE NUMBER:
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? 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:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid _ Toilet cleaners
a Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils _ Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
sphalt & roofing tar Leather dyes
Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
aint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
--1,44etal polishes (including chloroform, formaldehyde,
aundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business
rA
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
2.Printers
satisfactory
BOARD OF HEALTH 3.Auto Body Shops
unsatisfactory- 4.Manufacturers
COMPANY .1� (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS ? — Class: 7.Miscellaneous
QUANTITIES AND STORAGE (IN=indoors; OUT=outdoors)
MAJOR MATERIALS Case lots Drums Above Tanks Underground
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel (A)
1'e,0,0
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil (C)
new motor oil(C)
transmission/hydraulic
Synthetic Organics:
degreasers
1
Miscellaneous:
te"-
Lm
DISPOSAURECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply
0 Town Sewer OPublic
fOn-site VPrivate
3. Indoor Floor Drains YES NO U
0 Holding tank:MDC
O Catch basin/Dry well .�
0 On-site system
4. Outdoor Surface drains:YES NO ORDERS:
O Holding tank:MDC
O Catch basin/Dry well
0 On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product
YES NO
2.
Person (s) Interviewed Inspector Date >
t/0,�
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair 5
nters
BOARD OF HEALTH satisfactory 3.2.Auto Body Shops
0 unsatisfactory- 4.Manufacturers
COMPANY'�� X,e (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS 2441 -VT/Z/ 9 C18SS: 7 1 7.Miscellaneous
VIAe YF a_&,fAUANTITIES AND STORAGE (IN= indoors; OUT=outdoors)
MAJOR MATERIALS Case lots Drums Above Tanks Underground
„ ?d;R- rZ 911 IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel (A)
Diesel, Kerosene, #2 (B)
Heavy Oils: Jw
waste motor oil (C)
new motor oil (C)
transmission/hydraulic
Synthetic Organics:
degreasers
C4 :J42
Miscellaneous: dq
P
r/A;,
c
DISPOSAURECLAMATION REMARKS:
1. Sanitary Sewage 2. Water Supply
-cr �&0�-
O Town-Sewer OPublic
On-site 0rivate 10; --6 0" 4A,frer .,y �.�
3. Indoor Floor Drains YES NO i'
O Holding tank: MDC
O Catch basin/Dry well . CCz74,2r
O On-site system /
4. Outdoor Surface drains:YES NO P ;
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
5. Waste Transporter
Name of Hauler Destination Waste Product
1 YES NO
2.
Jv4n4�
Person (s) Interviewed Inspector Date