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HomeMy WebLinkAbout0031 INTERVALE LANE - Health 31 INTERVALE 1a\M MARSTONS MILLS A= 043 b``6 -- ---- - ' TOWN OF BARNSTABLE r a LO(;ATION l�l�t�'� SEWAGE # kco-LA--� 1i11 ASSESSOR'S MAP& LO (>I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (ty ) __� ��e� l (size) l G00 NO.OF BEDROOMS BUILDER OR OWNER 6 PERMTTDATE: 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) °��(���y, Feet Furnished by 175. i ✓�� y �r y IA mi G R o � c Ag y� 0 all w A D q � IL all �7 Commonwealth of Massachusetts Executive Office of Enviromnental Affairs ki Dept. of Environmental Protection T� One winter Street,Boston,Ma. 02108 �1 D.ET 'RA'11d-V tic. speetor 641 / / - . Teat',ket�WA 02 WILLIAM RWELD O ! �5R*to813 'rp Governor % - ARGEO PAUL CELLUCCI C� 1998 Lt.Governor TOWNOF SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM= EAITH ft D ABIF PART A H EO CERTIFICATION Property Address: 31 INTERVALE LANE MAR STSONS MILLS MAP 043-018 Address of Owner: Date of Inspection: 919198 (If different) Name of Inspector: JOHN GRACI MRS.PIETRONIRO:115 SCHOOL ST.MARSTONS MILLS I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This Inspection Is based on criteria defined In Title V — Conditionally aS5e5 code 310 CMR 16.303.My findings are of how the system is performing at the time of the inspection.My inspection does _ Needs F th r Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity ofthe Falls septic system and any of Its components useful life. Inspector's Signature: Date: 911119s The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B.C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of — .Co7riphance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection, or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127S7) One Winter Street to Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31 INTERVALE LANE MARSTSONS MILLS MAP 043-018 Owner: MRS.PIETRONIRO:115 SCHOOL ST.MARSTONS MILLS Date of Inspection:919198 _ Sewaae backup or.breakout or high static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the Surface of the ground or Surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 04127197) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31 INTERVALE LANE MARSTSONS MILLS MAP 043-018 Owner: MRS.PIETRONIRO:115 SCHOOL ST.MARSTONS MILLS Date of Inspection:919199 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 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. 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. E] LARGE SYSTEM FAILS: You -rust indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. trevlaed 04127.57) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 31 INTERVALE LANE MARSTSONS MILLS MAP 043.018 Owner: MRS.PIETRONIRO:115 SCHOOL ST.MARSTONS MILLS Date of Inspection:919198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes 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. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. -x— — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x _ The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revised 0427,97) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 31 INTERVALE LANE MARSTSONS MILLS MAP 043-018 Owner: MRS.PIETRONIRO:115 SCHOOL ST.MARSTONS MILLS Date of Inspectlon:919198 FLOW CONDITIONS RESIDENTIAL: Design flow: 3w g•p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No . Last date.of occupancy: MARCH1999 COMM ERCIAL/IN DUST RIAL: Type of establishment: nla Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nra Last date of occupancy: n1a OTHER:(Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: rda System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: nra TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date installed(if known)and source information: ORIGINAL SYSTEM IS 20 YEARS OLD,WITH A NEW PR INSTALLED IN 1993 BY ABCO Sewage odors detected when arriving at the site. (yes or no) No (revised 04127)97) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 INTERVALE LANE MARSTSONS MILLS MAP 043-018 Owner: MRS.PIETRONIRO:115 SCHOOL ST.MARSTONS MILLS Date of Inspection:919198 SEPTIC TANK: x (locate on site plan) Depth below grade: 1' Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age nla . Is age confirmed by Certificate of Compliance Nc (Yes/No) Dimensions: L8'6'•H5'7"w4'10" Sludge depth:6" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:2' Distance form bottom of scum to bottom of outlet tee or baffle: We How dimensions were determined: MEASURED Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERYTWO YEARS. GREASE TRAP:_ (locate on site plan) Depth below grade: rJa Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rva Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: rva Date of last pumping;,!. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rVa BUILDING SEWER: (Locate on site plan) Depth below grade: vs" Material iof construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line•TOWN Diamete-: nIa QNeImments: (conditions of joints, venting,evidence of leakage, etc.) (revised 0412TV7) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 INTERVALE LANE MARSTSONS MILLS MAP 043-018 Owner: MRS.PIETRONIRO:115 SCHOOL ST.MARSTONS MILLS Date of Inspection:919198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nra Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nre Capacity: r9a gallons Design flow: nra -gallons/day Alarmi level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan). Pumps in working order:(yes or no)No Alarms�in working order(yes or no)_ve: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) nra Irevleed 0411'1971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 INTERVALE LANE MARSTSONS MILLS MAP 043-018 Owner: MRS.PIETRONIRO:115 SCHOOL ST.MARSTONS MILLS Date of Inspection:919198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number: 2.1000 GALLON LEACH PITS leaching chambers, number:Na leaching galleries,number: rda leaching trenches, number, length: Na leaching fields, number, dimensions:Na overflow cesspool,number:Na Alternate system: Na Name of Technology:_Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. CESSPOOLS:_ (locate on site plan) Number and configuration: Na Depth-iop of liquid to inlet invert: Na Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na lndlcatian of groundwater: Na inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY: (locate on site plan) Material's of construction: Na Dimensions: Na Depth of solids: Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na (revised 0412797) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 31 INTERVALE LANE MARSTSONS MILLS MAP 043.018 MRS.PIETRONIRO:115 SCHOOL ST.MARSTONS MILLS 919198 'SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 0 W 6« 4A 10 Ag A o 4a FA ►� 6 �D y� (revised 0412il97) Pape 9 of 10 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 31 INTERVALE LANE MARSTSONS MILLS MAP 043-018 MRS.PIETRONIRO:115 SCHOOL ST.MARSTONS MILLS 919198 Depth of groundwater 11. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revised04W97) page 10 of 10 I - '- TOWN OF BARNSTABLE LOCATION SEWAGE VILLAGE tYl ASSESSOR'S MAP &; LOT( ' INSTALLER'S NAME &y PHONE NO. Ca\C,�� I W is 3`�;J`iU� z4-77_6 3" SEPTIC TANK CHPACITY LEACHING FAC.ILITY:(t-ype) `a (size) /Doo S svt NO. OF BEDROOMS PRIVATE 'WELL OR PUBLIC WATER BUILDER OR OWNER C,- Ic 0 DATE PERIRIT-ISSUED: f DATE ,COMPLIANCE ISSUED: 3 ^ S VARIANCE GRANTED: Yes No L n - --- - - NCIJ 16CO , P� u i ;N 1I i ,I t � 1 i C., TOWN OF BARNSTABLE LOCATION 3i '�.1f1��r�c,1E SEWAGE # J VILLAGE Cyl kv-S�0u TAV OS , ASSESSOR'S MAP & LOT&Y3 0/8 INSTALLER'S NAME & PHONE NO. LC�>Cp,,�, (`FQtu�V`iCl LI-77"03�� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) j.. T ,`� (size) /DDD NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 1 3 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No NCO tam . P; 0 l f _ �r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OWN OF BARNSTABLE Appliration for Divi-paiial Wnrkri Towitrnr -on rrrnnt Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal System at• � l � � .y. _...... 4 ..£..........� ---. ----••.----•-..----...............( •----... v.7 Lo ti\ddres C� r O r � o��t( � �i ...... .C. �............ `.. -- •------1-------------------------------------------••••................... ...................... Owner W !. ss:... s .:. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.--.......- -_-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons..........----.--...----.--. Showers ( ) Cafeteria ( ) 44 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 ( ) aPercolation Test Results Performed by........................................ ................................. Date........................................ ,-a Test Pit No. I................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--.....---.............. 9 •---•-•••-••----------------•-••••••••••••••----•-••----•-••••-•••••---••••-•-•••••••--•••..............---•••••-••-•-----....--•••••••••...............•••- 0 Description of Soil......... ---------------------------------------------------------------------------------------------------------------------- x W -••••••••••-----------------•--------------••--••••-----------...--•..........---------•----•-••••••. ---------------------------------- ------ ................................................ U Nature of Repairs or Alterations—Answer when applicable--------------- ---- - �. � .................... --------•-------------------•---------------------------------------•-------------••-••••--•--••••----.1- 9.• c------ ---- �- ------ ............................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environ tal Code—The undersigned further agrees not to place the system in operation until a Certificate of Com lan as b n issued by the board of ealth. / 9 Signed ---- ------� .. .. .... ------------------ 1 Dace Application Approved By ------------- ---- 1 t t_.A;k.7�3... Dace Application Disapproved for the following reasons- -----------------------------------------------------------------------------------------------------J..^ --^ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----1.............. .... Permit No. -----------73_-......575 -------------- Issued ................ .............. .............. ...... ....... Date------ 'y�� .- Dace x � O � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1_,4 3TOWN OF BARNSTABLE Appliratiun for Diti-pu3Ml Works Cnunitrnrtiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair �an Individual Sewage Disposal System at: i u 4 �G (_ Loca\ti. .,,?-Address sir-------- �----- I--L.. �. Owncr ,� -- ress ��e���: c ._ Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms---------- ___________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) al 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 ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-___-_-.-__-_____• Depth to ground water........................ fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................... 9 -------------------------------•--•----•---------•-----•------•••-•-• ....................................................................................... .P ....•---------••......•........... ... •>;;, --- x Descri tion of Soil -` � . -- --•- ................................................................................................................. U v UW ••-••••----•----------------------------•-------•••-----------......•---•---------------•-----•-•-•-- .................................... ............................................................. Nature of Repairs or Alterations—Answer when applicable-----------7`t-.t „...`__.... ...!N e ms...................... -•--------- --...-------•---------------------•---------------------..1 U� - = = Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Enviro��jfm,&ntal Code—The undersigned further agrees not to place the system in operation until a Certificate of Com �iYan�has been issued by the board of health Signed -------- -------1. --/1-­-a Dale Application Approved By ------------( ..... -.)-e r .,2��_-..e, .................... .............. ./...�. --...a�...� .3.... Dare Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------f..... -- - t� ....................... -------------------------- _ - - - � --------------------------........... ..............................------------------------------ ------------------------ ------------------- ---- ..... ..... ...... ...1�5. . Dare Permit No- ------------ -Y I�.........�...._.............. Issued /.. C� 1 `3 ------------------------------------------------- Dare _ —___._----__.______ __ — _._.__—_,_ —_,._. _ _______---_______.__ _.—_._ — _J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Te>r#ifira e of Tomplianre THIS I 'IT ICERTIFY, That the Individual Sewage Di�. osal System co strutted ( ) or Repaired 4, 1 -f e, �Vc -------------------------------- by ---------------- - .........�s... �._.. C�--..1 .. � ..Y _4...._.... .._. - '-----Installer at .......................5 1.... --------._,,...... (, . -r ... - - -` - - 5.............. .. .. 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. ........F-3-.=-----_- ..`� dated -----------------------._------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �} DATE---------- �.-..^ - ------------------------------ Inspector -----------0 ------------------------------------ ------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ? Shy FEED©._off �tu�rnuttl urku unutrudiun rrr4 it Permission is hereby granted =�'t ` `'� d r --C=.CS------....-••---- to Construct ( ) or Repair r-?L•}-an individual Sewage Disposal System ( ' atNo.- �.�I.. 4-•--- `-- �-`-`-- --=q------- q --r-- �.... .S.............................. Stree as shown on the application for Disposal Works Construction Permit tNo..r�-S/S/Dated....Lf... ... .." -�.�..._. •-•----------------•------•----- �f .r_ ------------ ---------------------------------------•••-- DATE...... a •-- ( � -- -----•---•---•-•-••---••------------• Board of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS L o // L9CAYION � r����/ SEWAGE Pg.-"MIT oNO. z e��. VILLAGE J o /-? 07 15�V/7<0 INSTALLER'S NAME i ADDRESS . AAr BAG HO -: li?LOH ,ter{�tCi Ifni it �tre Wed Barnstable, Mass. 02668 BUILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED iz-A-t 71d: . , :r � '` � � b. �� �� 3� ,, -. y7 ' 6 No......W.... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .w.. 7.........OF......, .r�2._M5 Gt_!�./�...................... Allp ira#ion for Uwpaoa1 Workii Toustrudiou rruti# Application is hereby made for a Permit to Construct (� ) or Repair ( ) an Individual Sewa a Di s osal Syst at; f / / ' /2. ��a e /12 )�� �� � �f ,�'a�'�5��/��� ���v�v r, .d...�� ............................................. - .. ... ._........ I capon-Address t ...-C.- •4nstal Address_. p.. - W .... -----...-•-------•-••-----•-------••-•-----------------------------------------------------•--•--- -.. (�`� Address 7 d Type of Building Size Lot..........e- �..-�---Sq. feet Av V Dwelling—No. of Bedrooms.....................................Expansion Attic )� Garbage Grinder ( Z? aOther—Type of Building ............................ No. of persons-_-------_.-----__-__----- Showers ( ) — Cafeteria ( ) dOther fixtures ------------•----------------------•-------••--------------------•---------------------.-------------..---------0;--••-•-------------.------------ Design Flow......... ....................gallons per person er d�.�Total daiV flow__..._..__..__...-....................gallons. W s� WSeptic Tank—Liquid capacity-/00gallons Length... s!.._._ Width...`'........... Diameter................ Depth__ !__....__. x Disposal Trench—No. .................... Width.................. Total Length................f.... Total leaching area....................sq. ft. ... . ___.... Diameter........_.___. Depth below inlet........ ...... . tal Itching area..92.a Z....sq. ft. Seepage Pit No.._ .�... Other Distribution box {' ) Dosing tank ® ,.., � Percolation Test Results Performed by._..,�,._ __. ......;._...�_ .._____.�.._ ._. . _. -..���---�,;- -----•-- • -max a Test Pit No. 1_..._� ..___minutes per inch Depth of Test Plt....... ......... Depth to ground water._ ___ _4.._. � .. s Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ..................................-- ............C.................................................1 --------------------------------------------- O Description of Soil .----- •. 7.._f y!.. --••-----•---..--...-•-----•.-O •fr ' �Q�'' W ---•---------------------------------------------------------------------•-------------------•----------------------------------...------------------........................................ txj 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 TL ITL 1 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. Sig d --- -------•-------•----__..._ ..._ Application Approved B ;�f ............... -•- --- �� � PP PP y----•- u_._... .-- ---- •-•---.Da----------------- • Date Application Disapproved for the following reasons:.................. -•----------------------------------•--------------------•--••-------------------•••-----•••. ...............•----•-•----•-----•..........----•------------••----•-----•---•--••------.........-------•---•••----•-•-----. ---•--------•-----•.------------------•--------------................ 41 a Permit No......................................................... Issued...�� - -�}-n ... •. - "------. 0/ i3...=;.7. .......... No.... ..t_.�g yy FE THE COMMON ALTH OF MASSACHUSETTS Lj BOARD OF4,\H EA T .......OF....... . ............................................ for Bhipaoal Works Tonstrurtion Vamit -Applf&tion is hereby made for a Permit to Construct X or Repair. an Individual Sewage Di posal \,System at: 'Ile 6b A)1-i 77 uz:�' ... ..................................................... ................................ ........ ............. Lot ........... ............... ....... Address ..r,x a ... .............F,........... .......... .........................I............ .................... ........................................................................ ............fx'�..... Installer Address ? �t c2O �7AP s f t Type��Building Size Lo ..........*................ q. feet U Bedrooms._...__..Z.............................Expansion.Attic�ye�s Garbage Grinder (Vo Dwelling—No. of Bedro 4 R�r�o�� ............................. Showers Cafeteria 04 Other—Type of Building ............................ No. of . s 04 Other fixtures ...................................................................................................................................................... 9� Design Flow...._:...sS-U.....................gallons per person Der I dam.1 Width_.._.__.___.Total daily flow..__...��A©.._.........._._____gallons.eptic TankF. ..... W .16......... Diameter________________ Depth... Liquid capacity,/O.Ci2allons Length... F..7 Disposal Trench—No..................... Width_..._. __._.__.____ Total Length._._-______._ Total leaching area....................sq. ft. ej Seepage, Pit No......../.......... Diameter.___�r......... Depth below inlet...../-- .h' ;7^.,T hi p.a.j4?l...sq. f t. Z Other Distribution box Dosing tank 0 �_4 Percolation Test Results Performed by.... _.__.minutes per inch Depth of Test ........6........ Depth to ground water -Test Pit No. I.....0 ?irt................................... Date.....$?/ ....6.101 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Death.Lo ground water_.._____.__.___._____._. .............................. ...........r........................................ 0------------ ------ ----------------------------------- 0 Description of ...... ........TX.100.qrks C ....... . .................................................................................................................... ...........() ---------------------- ----­------------ ....................................................................................................................1................................................................................... 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 Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued bylt board of health. Sign ....i.19............I....................................................... ...................... . .............. Date Application Approved By...... Va4t /*#e f 0, ------ ..... .. ..... Date Application Disapproved for the following reasons:.................................................................................................................. ....................................................................................................................................................................................................... Date PermitNo.................................. ..................... IssuedL..................D..................................... ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... .....OF........... ....................................... (Intifiratp of Toutpliatta THIS�is 1446 CER I Y, t,the Individual Sewage Disposal S-�,stem constructed or Repaired ":10 .......... . ....... all by.....=...A. ... 4�F------------------------ ----------------------- inst A 0 :7 .4 ................. ........................ ..............e... ...... ---------­-------------- ............................... at........ ..eyF--------------------------------- has been instilled in accordance with the provisions of TI'l 5,64,0ae State Sanitary C9de,;p§-&qkribed in the application for Disposal Works Construction Permit No_________________________________________ dated_...._.__......_...._.._.__....___.._.__.____... THE ISSUANCE OF THIS CER. IrACATE SHALL NOT BE CONSTRUED A S)A GUARANTEE THAT THE SYSTEM WILL.1%FtOOKC AT , OR.Y. DATE............... .................................................... Inspector.................................................................................... THE COMMONWEALTH' OF MASSACHUSETTS BOARD OF HEALTH 0;�47 7 ............ .............................OF...........0.14-. ................................................. ....................... No......................... FEE....._................... Diavoffal/3vor Towitnuton "prrmit Permission is hereby granted_e:�...... ......... . ..................... ..................................... div*16V oy i p 1,S y/ to Constru5ti Y_or Repair an In 7�agq b.�e "O"il Ts,a L�� 12 '/­.......I.............. .......... ................................................................... --------- at No.......a r Street2 Perrrfi ------ ------------------ as shown on the application for Disposal Works ConstructionIt/ ........ . ........ Board of Health DATE. --------------- ........................*----------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS P. i ���I�d Jr- TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: Dy5T 0-P +4 e )5a r_tk Mail To: BUSINESS LOCATION: 3 1 j:n Te y-✓Ale L a YI & Board of Health MAILING ADDRESS: 3 i j vi to r VA I -e- Town of Barnstable P.O. Box 534 TELEPHONE NUMBER: q 3. q g S q I Hyannis, 3 02601 CONTACT PERSON: w/� � f�` o ni v-o EMERGENCY CONTACT TELEPHONE NUMBER: Does your firm store any, f the toxic or hazardous materials listed below, either for sale or for your own use, in quantities toy ing, 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 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 Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & 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, Metal polishes (including chloroform, formaldehyde, Laundry 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) IJ s-( cv�a rr.�-r Other cleaning solvents rvt �(, c Cam, , Bug and tar removers /A�, Household cleansers, oven cleaners 6" �zbr- .bJA,t !,e 2X White Copy-Health Department/ Canary Copy-Business LJ L r t � ! T/?iAl 77f -r � � � + v�``" � ,.,•.. ✓i`��fir' S.; L��'/ V%,� Y��^t"/`'+'. 'f` "".��.. �r L � I f i 7 % T 3 Y v y r r 14 .� `b '� c �` � � `` r r/��Or �Cn1 � �A/'�L'f f..�.71•-�� � /-r Jy 2'' � O ` ,]t" 1� -+ 3 1 � U 7'F #mot- S;!'S".°": ,y, 00 1-4 .s, a/ 7 FRANK , j 1 G �t� CCNERY Na. �2?2 L e 9 NC 55' h f v 'F! ,r . OF LAND M AS tN OWNED aY Tevp FRANK CONERY 5 TREN7ON aT. HYANNiS. MASS. 6001 -*-G�STSR£D 9M#IUWEYR R LAND GVfrlfEYC•IW SCALE 1 I -26) T. r i Z