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Home My WebLink About0061 FLEETWOOD PATH - Health 61 F1e.etwoo.d Patl ]raj S'ion;s Mills A=,046--073 --Hazardous Materials Inventory Sheet Checklist ,S p Date Physical Street Address-Check database to ensure it exists y Working Phone Number Z_ Actual Amounts -( ie. gas being used to fuel machines, thinner to - clean brushes-all count as hazardous materials-no blanks) �- Storage Information -.location of storage, how long is storage for? If none, note that. Disposal Information -where and who? If none, note that. Applicant Signature understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and explain it Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of,and the procedures they are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years]. A business certificate ONLY.REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to opera' ate.)You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: —1D" Fill in please: APPLICANT'S YOUR NAME/S: , J A ti 06 iz.S C7r(/ C' S T-6 L. 1"6 BUSINESS YOUR HOME ADDRESS: ( IF L C%c T` 1z622� PA'f/� /V L I L 01 TELEPHONE # Home Telephone Number IOZG� NAME OF CORPORATION. NAME OF:;NEW BUSINESS /1) riF 5 GLrli i4�+Ca�s'i TYPE OF BUSINE rxi7 . IS THIS A HOME:OCCUPATION� _YES NO ADDRESS,OF BUSINESS �'. — s ,t/�: Z�5 MAP/PARCEL NUMBER h G. (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally opera o t t ss in this town. /,,-1. BUILDING COMMISSIO ER'S Off-ICE This individ[ al h lb g� � a{ny per it requ^ir�ments that pertain to this type of business. MUST COMPLY WITH HOME OCCUPATION lnforme �J r iu _.( ,�f �p.0� � . RULES AND REGULATIONS. FAILURE TO Author' d igna �e** COMPLY MAY RESULT IN FINES, CIO r 2. BOARD OF HEALTH This individual ha formed o t e peP mit re reiFeme is hat pertain to this type of business. / COMMENTS: Authorized Signat a MST SLY%R,H ALL 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: 1 . Date: S TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: A L I/GS j! L,G6,0.,1 t,co Ik /<,) <oAvS -r BUSINESS LOCATION: Val r(V_s -r0x/9 A4 r I_a_ % INVENTORY MAILING ADDRESS: A 4 f'tccr Ctlnor) Pporm , A44+re5-f0AeT-i AAt P_r_ s TOTAL AMOUNT: TELEPHONE NUMBER: Sog' 360 107,0 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: S99'3bo!®Zo MSDS ON SITE? TYPE OF BUSINESS: L 14-.A- D SChVE Clew INFORMATION/RECOMMENDATIONS: Fire District: S tD tt'E t A,- NAY -Va f G r, ... Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazaous mataial u , storage and disposal of 111 gallons or more a month requires a license from the Publ -lealth C#misioda LIST OF TOXIC AND HAZARDOUS MATERIALS 0 The board of health and the Public Health Division have determined that the followin0P roducts !3.3ihibit xic or hazardous characteristics and must be registered regardless of volume. s Observed / Maximum Observed / Maximum 00 5-1 Antifreeze (for gasoline or coolant systems) Miscellaneous Irrosive rrn ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) S Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED (yL Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible 6L Car wash detergents Leather dyes Car waxes and polishes I Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials I �Q«� �0(q 07�� i67 rA Piz' ✓r�V � y7 l l ro i N I ® Go016G 5 ca 1 v i e� ` , ^� 1/ / WWW SMOKE TECTURS R�VIE.�W5 (� CARBON MONOXIDE ALARMS f I BARNSTABLE BUI IN PT. TE MUST BE INSTALLED PER j MASSACHUSETTS BUILDING CODE _ I �J 1. F ARTMEN7 DATE Illl BOTH GNATURES ARE REQUIRED FOR PER ITTING i �. IMPORTANT - UPGRADE REQUIRED STATE BUILDING CODE REQUIRES THE UPGRADING OF SMOKE DETECTORS FOR THE ENTIRE DWELLINQ(WHEN ONE OR MORE SLEEPING AREAS ARE ADDED OR CREATED. i NOTE: A SEPARATE PERMIT IS REQUIRED FOR THE INSTALLATION OF SMOKE DETECTORS-THE ELECTRICAL PERMIT DOES NOT SATISFY THIS REQUIREMENT, I I v A praisals Plus Inc. SKETCH ADDENDUM File No. MM706004 Borrower Oliveira Case No. Property Address 61 Fleetwood Path f s City Marston Mills/Bam. County Barnstable State MA Zip Code 02648 Lender/Client American Home Mortgage Address 2 Oak Street Mashpee MA 02649 Note:Not to scale ; \1�jCTU US� 40 JJ Bath Bath Bedroom 21' Bedroom 21' Bedroom S � 4 64' I Dining KAchen Bath 24 Family Roan 2fr Q FPL Living Room Bedroom 24 4' '✓ 40 { J I ClickFORMS Appraisal Software 80.0-622-8727 Page 4 of '11 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^H owl - 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. Cityrrown Inspection results must be submitted on this form. Inspection forms may not be altered in any way. 6 Important: A. General Information When filling out forms on the computer,use 1, Inspector: only the tab key to move your MICHAEL DEDECKO cursor-do not Name of Inspector use the return key. COMPASS REALTY DEV CORP Company Name reD P.O. BOX 2384 Company Address M MA 02649 ASHPEE Brwn City/Town State Zip Code 508-221-5003 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: {f N ® Passes ❑ Conditionally Passes ❑ ails ❑ Needs Further Evaluation by the Local Approving Authority .clt 4 5/21/07 spector's Signature Date c:1 rYt The system inspector shall submit a copy of this inspection report to the Ap oving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 241 pine•08106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 241 pine-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 241 pine•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. City/town B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters El due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ® Required pumping more than 4 times in the last year NOT due to clogged or El obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 241 pine-08106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. CityrTown B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 241 pine•08/06 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. City/Town C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 241 pine•08106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,w 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. city/Town D. System Information Residential Flow Conditions: 4 Number of bedrooms (design): 4 Number of bedrooms (actual): 440 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 0 Number o-current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No n/a Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No N/A Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water mieter readings, if available: Last date of occupancy/use: Date Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 241 pine•08/06 Commonwealth of Massachusetts W Title 5 Official Inspection Form Form -Not for Voluntary Assessments Subsurface Sewage Disposal System 61 FLEETWOOD PATH Property Address CIO TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection evert page. cityrrown D. System Information (cont.) General Information Pumping Records: n/a Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and ❑ maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 241 pine-08/06 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02548 5/21/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight yes vented no sign of leakage. Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) e: If tank Is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------500 gallons 1 Dimensions: I 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 31" 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 11" Distance from bottom of scum to bottom of outlet tee or baffle 14" measured How were dimensions determined? 241 pine-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. cityrrown D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): no need to pump tee's intact structurally sound liquid level equal with outlet invert, no leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 241 pine-08106 Commonwealth of Massachusetts. Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ww 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): equal with outlet invert Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box is level and distribution is equal, no solid carryover, no signs of leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 241 pine•08/06 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 2 ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): soil sand/gravel, no sign of hydraulic failure, ponding dry, no damp soil, vegetation normal. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 241 pine•08106 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. city/Town D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (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 Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 241 pine•08/06 Commonwealth of Massachusetts Title 5 Official inspection Fo rm rm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. � 2 l�3 -7v 241 pine-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments +M 61 FLEETWOOD PATH Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is MARSTONS MILLS MA 02548 5/21/07 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 90, Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: barnstable gis ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: barnstable gis shows spot elevation 97.44 241 pine•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF BARNSTABLE v LOCATIO GvcPrff /05/f SEWAGE # —Q10 VILLAGE ASSESSOR'S MAP 6z LOTC � INSTALLER'S NAME PHONE NO. A,,N477;�- 0; 4w-!f SEPTIC TANK CAPACITY f�0® LEACHING FACILITY:(t pe) lood 60t.. Pr7'5,-,?' fir lT ' NO. OF BEDROOMS INuVAnn WEL3 R/y VB P BL C WATER BUILDER OR OWNER P,D/j DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: "' VARIANCE GRANTED: Yes No L/ r a 57 ' 16 61 v t` 6 IbW COU-0-1 THE COMMONWEALTH OF MASSACHUSETTS' BOAR® OF HEALTH 7 8 Sl TOWN OF BARNSTABLE Appliration for Disposal Worko Tonstrurttinn Prrutit Application is hereby made for a Permit to Construct (-kl) or Repair ( ) an Individual Sewage Disposal System at: ----- Location,�/I -Address s or Lot No. lr3C .�tk�----------- -•••....._ �.p_._�'a0@d Own r O Address w � T�------------------------------------------ � C- 2�... � ..-- •----- •..................... ..---•-•--....--•--.........---- Installer Address UType of Building Size Lot--- ......Sq. feet Dwelling—No. of Bedrooms---------_5P................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g --------•------•-----------• -•----- --- ( ) — Cafeteria ( ) Other fixtures _ =+ :.....:---------------- w Design Flow.................................-r'S-•._gallons per person per day. Total daily flow.. ,.. .........•......4--•--- --_gallons. WSeptic Tank—Liquid capacity)-` ...gallons Length_Aq"6__. Width-'_.-_.P__ Diameter_`...... Depth_s':977 x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area-__:................sq. ft. Seepage Pit No.......2............ Diameter......`,1...___..__ Depth below inlet......4.......... Total leaching area'.+(alo...sq. ft. , Z Other Distribution box ( wl Dosing tank ( ) '~ Percolation Test Results Performed y.R............................. Date.._-C_7-�_.-.F..Z_...._......._.. Test Pit No. 1411WX----minutes per inch Depth of Test Pit___ Depth to ground water.._'._..--__-. 44 Test Pit No. 2-4V0 Z.minutes per inch Depth of Test Pit...IZ.C.... Depth to ground water....:................... a •--•----•----••••••---•-••--•••-•--•......---•••-••-•---•---•. ............•-----•---------••--•------------- O Description of Soil--- --•--•-- 5 _ %lt.�Ck, T ------ -----------.......................... x U ......--•••••••--•-•-•--....-•-••••---•-._.....•••----•--••--•••--•-•-••........•••••••--•--••-•••-•••••••-•-••-----•--••----•••----••---••-----•--•-•--------------••.....------••---...........-----••. w UNature of Repairs or Alterations—Answer when applicable.............................•______......... ............................................ ----------------------------•-------------------------•----------------------...--------•-•--•--------------...-------------------•--------...------------------------------------------...........•••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code The undersigned further agrees not to place the system in operation until a Certificate of Complia has b n ' sue board of health. - Signed . --------------------------------------=-- = ` Dace cy Application Approved BY `� ... _ ------1--y` V J �ifNrc- -- ------------ Date ' t Application Disapproved for the following reasons- ............................................................. ----------------------............................................. ---- -------------------------------------------- ------------------------------------------------------------ --- ------------------------------------------------------------------------- PermitNo. .---?.-�---- ..D.------_----------------_ Issued ---------------------------------- -- ----...------ Dale THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH 78S O TOWN F BARNSTABLE O Appliruiion for DiuVntttl Works Tonstrurtion Fautit Application is hereby made for a Permit to Construct (k ) or Repair ( ) an Individual Sewage Disposal System at: s6/ i G T+,,ioo ................_ -.................. •---•-...............�Y•'�............ '-----------`/ ---•-•- -•--}�- - ............................................... Location-Address or Lot No. lq,2S!g2 e . . C!ly..rfr,r -tS�tpn,_J?na := FrA.1.►!�.[!1!:�:h..�� {G /�y/Own r �}' y' Address / W6J t� v(( ..... 0 ��'.......................................... �"�T_.._........ ,-I Installer Address d _Type of Building Size Lot..Ae.7.7Q......Sq. feet U Dwelling—No. of Bedrooms.._.._...r' ..............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria QI Other fixtures .................................. W Design Flow................................iOr•.S.___gallons per person per day. Total daily flow___P5�6!P..............................gallons. WSeptic Tank—Liquid-capacity-�9a..gallons Length._/P.'6'` Width-5-_ `. Diameter. ..... Depth.5=,e".. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_...................sq. ft. Seepage Pit No.......Z----------- Diameter------ll__�_______ Depth below inlet......4.......... Total leaching area..+-pl r...sq. ft. Z Other Distribution box ( v) Dosing tank ( ) Percolation Test Results Performed 4? ............................ Date.2. ........................ Test Pit No. 1!F9S Z____minutes per inch Depth of Test Pit-__,� �S.____: Depth to ground water....--"':'-.....----- (�, Test Pit No. 2 MX Z.minutes per inch Depth of Test Pit...lZ r�.... Depth to ground water.....---............ D Description of Soil -- ------------------------------------------------------------------------- ---------------- --------------------------------- .----------------------- U ......�5 --- -------�-�'"' 5� -r! .�'��T k�-----`--- ---- a11°�'��------------------•-••-•----•---- W ...............-....................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------------------------------•-•-------------------------------•---------------------------------------.....•---------------------......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place.the system in operation until a Certificate of Complia has b ssu e board of health. Signed ----_ --- --- -- ------------------------------------------------------------ .......7...... ------ Dve ApplicationApproved By ------------- � ..---...---------------------------------------------_...-------....-- ---_- --�. it Dwe Application Disapproved for the following reasons- ------------------------------------ -- ..........----------------------..:r..........----...-------------------------------------- ------------------------------------------- - -- --- -------- ---------------------------------------------------------------------------------------------------------------------------- --------------------------------------- Date PermitNo. ....?--y...- .1 1............................ Issued -----------------------Datete........................ t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#tfirate of Tomplian e THIS IS TO CERTIFY, 1h2.t the Individual Sewage Disposal System constructed or Repaired ( ) by.......................a)---_-------A^' --- 1� Installer at .... (�----/----------1__424 --- --- --------_------ 12, b ---------------.--- --...... -----.....------.....----------....-- ---------------- --..... --.........------------------ --.---- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...... ..:...- ..... --- dated ................----------...................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � � DATE.. -- -------------------- -------------- - _ Inspe.tor _ - ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH pp TOWN OF BARNSTABLE ... Disposal Worho Tonutrnr#iott rrutit Permission is hereby granted. ....---- - to Construct (k) or Repair ( ) an I ividual Sewage Disposal System atNo.---- ------- < - ..........� .'1............. *....................................................-.......................... Street o as shown on the application for Disposal Works Construction Permit No.%_ .y�� .. Dated.......................................... ................•-------•---------------------------------------------•-----••.-- Board of Health DATE................................................................................ FORM 36508 H088S h WARREN.INC.,PUBLISHERS ,r r 327 '; f ` l�t 320 , � rl Az, , I00% &xp. ath . {u� 328 j Lam,— 3�9 I c Flo ,'��,�• � l . ..,.,, �• ¢p of 7,D` F 01 K 35 11D ►� ,1 v� it • I I II �, 3i I'' f T?i 3�LLCC f3 I. 1 Stk IA', ; 333 .dot 318 � 1 Notic, 31 "444 bedaooad A.11, C� e � �Scu�e 1 -SO I cap �'ty'>:"� e�,�rub septic, tank 1 f00 -bate 7-9-93 a9;Ida2bot l�oaa act U68'r1 i;au. /2-13-93 Alfa , rw 02601 fz uee 4 Cap aci tcf 88.2 gpd Sao jite, lVo sr-ate, Iva U, 000 .I lilt- ,W12 11,ton� Slzptch /.plan 01 ,Pa,nd .in Ma r tDo Mi,Us, M9 �. r C # 0751 �_..... ,se�nry �o�t 319 ati shown on .e. 3 ...� C eua iom, ace on aA a44umed datum. �a�te_---A�.ent:-Raz►v�;tc<.rZe r�aira"o�-rrdea:l,�h j �ij ' Sle,it Pit #P-7851 d Made 2-13-92 No w at eh enco untested p Leas. 2 min. , p etc. �7p1 9 P 2 I 34•t � � � 32.9 i � f4,and Y }-,Yt4l�Yl.(J \ IN 1 coav� ► fJ�^ I4 I Pr9tl{VIC l ._ 21.7