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HomeMy WebLinkAbout0296 LAKE SHORE DRIVE - Health 296 LAKESHORE Qt\�4vMARST.MILLS A= YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates COST $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO BY M.G.L. - it does not give you permission to operate). 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' FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. ' t DATE: U d 4 e � Fes ` Fill in please: APPLICANT'S YOUR NAME: iYe BUSINESS YOUR HOME ADDRESS: 7 y!� ;�/;'iJ Ci�•�/o ji/ 1 TELEPHONE # Home Telephone Number: — NAME OF NEW BUSINESS Scc,.3 TYPE OF BUSINESS IS THIS A HOME.OCCUPATION? YES O Have you been given approval from the building:division? YES NO �� G ADDRESS OF BUSINESS ZI�G /'7, y''I,%l" GZ , MAP/PARCEL NUMBER l� 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 operate your business.in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual han inform of t e permi require nts that pertain to this type of business. Authorize Sig ture** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Hazardo!L&Materials Inventory Sheet Checklist ate L—Fify—skal Street Address-Check database to ensure it exists �rking Phone Number __L,=-Artual Amounts-(i.e.gas being used to fuel machines,thinner to clean brushes all count as hazardous materials) moorage Information-location of storage,how long is storage for? If none,note that. C—Disposal Information-where and who? If none,note that. �t�Applicant Signature-understand what is listed and noted. �taff Initial-any questions,know who to ask. Vehicle Washing/Rinsing?-provide a vehicle washing policy and explain it-note that it was given. 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 Dater / � /dam TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: ame, L��n/_;c�a BUSINESS LOCATION: Z�1,��e o_ SCAM I)r M. mjl(S MA- (32C_1- INVENTORY MAILING ADDRESS: ?.A &i2 C�l' Uo'IIp Nh)4- �32G,ti�S TOTAL AMOUNT: TELEPHONE NUMBER: - Lf2%- -CD s`d CONTACT PERSON: rg-11 R nc, EMERGENCY CONTACT TELEPHONE NUMBER: Sb1r- '4,/W-5CZ 13 MSDS ON SITE? TYPE OF BUSINESS: Leti, .See.�i n l INFORMATION/RECOMMENDATIONS: Fire District: 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, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum G Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides EW USED (insecticides, herbicides, rodenticides) aso i e, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED 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 Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes m be toxic or hazardous (please list): 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 2 r 6 2040 f •T�f �b COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 030. 09S v Name of Owner BILL QUILLEN Address of Owner: 296 LAKESHORE DR MARSTONS MILLS,MA 02648 Date of Inspection: 10/10/00 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT t 1 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 _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 10111/00 The System Inspector shall s bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 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. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M, inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. 7 1) revised 9/2/98 Pane 1 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 Name of Owner BILL QUILLEN Date of Inspection: 10/10/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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 o the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y, N,or ND).Describe basis of determination in all instances. If"not determined",explain why not. n/a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance,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 complying septic tank as approved by the Board of Health. n/a Sewage backup"or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed distribution box is levelled or replaced n/a 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 -fx I revised 9/2/98 Paoe 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 Name of Owner BILL QUILLEN Date of Inspection: 10/10/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require.furthet,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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I: NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, •aal:- 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla (approximation not valid). 3) OTHER n/a r revised 9/2/98 Paae 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 Name of Owner BILL QUILLEN Date of Inspection: 10110/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: a I have determined that one or more of the following failure conditions exist as described 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 X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. _ X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone I of a public well. f; _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well, _ X 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 must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: 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 X the system is within 400 feet of a surface drinking water supply X the system is within 206 feet of a tributary to a surface drinking water supply 3 X 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) , The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the Department for further information. itf revised 9/2/98 Paae 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 Name of Owner: BILL QUILLEN Date of Inspection: 10/10/00 Check if the following have been don-3:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X _ As built plans have been Dbtained 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.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information,For example,Plan at B4O,H, X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. i revised 9/2 98 Pape 5 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 Name of Owner BILL QUILLEN Date of Inspection: 10/10/00 FLOW CONDITIONS RESIDENTIAL Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 4 ;Number of bedrooms(actual):n/a Total DESIGN flow: 440 gpd Number of current residents:2 Garbage grinder(yes or no): NO Laundry(separate system)(yes or no): NO If:yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow: n/a 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: n/a Last date of occupancy:n/a i iE OTHER: (Describe) n/a GENERAL INFORMATION i PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping: n/a TYPE OF SYSTEM X 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a I tii APPROXIMATE AGE of all components�date installed(if known)and source of information: 1997 Sewage odors detected when arriving at the site:(yes or no): NO :r revised 9/2198 Paae 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 Name of Owner BILL QUILLEN Date of Inspection: 10/10/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 10" Material of construction: _ cast iron _ 40 Pvc X other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 4" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 150OG L 10'6"H 5'6"W 5'8"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a 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.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SEPTIC SYSTEM'S EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. I{,u1 GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: nla Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: nla Comments: x (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.) n1a J (rq revised 9/2198 Paoe 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 Name of Owner BILL QUILLEN Date of Inspection: 10/10/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth(below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a c DISTRIBUTION BOX:X (locate on site plan) .`? Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Paoe 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 Name of Owner BILL QUILLEN Date of Inspection: 10/10100 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(n/a)n/a leaching chambers,number: (5)INFULTRATORS leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (nla)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY. CESSPOOLS: _ (locate on site plan) .,y_ Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: nla Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO -'r Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a u M-: PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: nla u Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2/98 Paae 9 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 Name of Owner BILL QUILLEN Date of Inspection: 10110/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) J m A �eCl� loll qC L+aL �'c 6� revised 9/2!98 Pape 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 296 LAKESHORE DR MARSTONS MILLS, MA 02648 Name of Owner BILL QUILLEN Date of Inspection: 10/10/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet n/a Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data i Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12 FEET revised 9/2/98 Paae 11 of 11 r - . TOWN OF BARNSTABLE V eLOCXTION 2 qi� SEWAGE # F7'� cVILLAGE s �1S�D�PS' �i��/� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. iSev SEPTIC TANK CAPACITY aj LEACHING FACILITY: (type)1 a�L c�rS �� (size) /O k 9' 42 ' NO.OF BEDROOe��P� MS 7 BUILDER OR PERMITDATE: I7— COMPLIANCE DATE: Z y tr— 77 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Sf Feet Private Water,Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Peon r:. `! by TOWN OF B TABLE LC ' .TION SEWAGE VILLAGE ASSESSOR'S MAP C* INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet. Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by . Y�� ` Yl��`A�� ��� i. 1 � _ _F �:� �l. °�<<` D �.S .�/�F �? _�,= No. _ � 5 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for 33tgaal 6pgtem Cow6truction Verrmit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System F Individual Components Location Address or Lot No. �QA� 44/�_1;ie fe ® r Owner's Name,Address and Tel. o. Assessor's Map/Parcel [ �7"v' � �Q�/ ,57W5lq;113 Installer's Name,Address,and Tel.No. f Designer's Name,Address and Tel.No. B0/� ' 4041 4P,94 77/93� Type of Building: Dwelling No.of Bedrooms V Lot Size sq.ft. Garbage Grinder(� Other Type of Building moo. of Persons Showers( ) Cafeteria( ) Other Fixtures �1 Design Flow 149 gallons per day. Calculated daily flow �7 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. LS ��Yl� /7�/� Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his B of ealth. o��7 Signed Date Application Approved by Date f2- V �7 Application Disapproved for th ollowi g reasons Permit No. q Date Issued p cyr y No. 7-2 � 1 / .. �::, r��,,, Fee�— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,. MASSACHUSETTS , ..� 01pprication for Migogal bpgtem Congtruction Permit Application fora Permit to Construct( )Repair(t/)Upgrade( )Abandon( ) El Complete System E ndividual Components Location Address or Lot No. pe Owner's Name,Address and Tel.Vo. Assessor's Map/Parcel /9e, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. B®!'7�P4t,/#i Cony 77/��39 Type of Building: Dwelling No.of Bedrooms 41 Lot Size sq.ft. Garbage Grinder(X-P Other Type of Building 14,04�4ao.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow ��Q gallons per day. Calculated daily flow 47 41� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. �Q.YI•�l/7 a�'/� Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is B of -ealth. - f Signed Date lZ Z 1 Application Approved by Date l0- 5 7 Application Disapproved for the ollowi g reasons Permit No. 9 Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Div os .5 - BARNSTABLE, MASSACHUSETTS (Certificate of Compliance `� r THIS IS TO CERJIFY,th t the n-site Sewage Disposal System Constructed( )Repaired ( ✓<Upgraded( ) Abandoned( )by j'! 7;- _� at Z 6$&re has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7- dated I Z-Z -9-7 Installer Designer The issuance of this permit shall not be construed as a guarantee that the syst ill f i �desigrjed Date Inspector --------------------------------------- No. 030 _e195— Fee THE COMMONWEALTH OF MASSACHUSETTS } PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Zigpogar bpgtem Congtruction Permit Permission is hereby granted o Construct( )Repair( 41Upgrade( )Abandon( ) System located at 2- cw oe� 1-e er. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this per1rK Date: J �- - cL/ 7 Approved by 10/9197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 17-1Z-/ 9 7 , concerning the property located at 296 G �eets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility ere are no private wells within 150 feet of the proposed septic system VY/There There is no increase in flow and/or change in use proposed are no variances requested or needed. /if the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. Please complete the following: ZZ A)Top of Cround Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Elevation(according to Health Division well map) �© SIGNED : DATE: �5;y LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder.art N� d S AA, i c-e-S l O ` lrm�� � i �y � LlG ILI U'� JAA Pi s I TOWN OF BARNSTABLE UV -',::'LOCATION Z ql% C4 SEWAGE# ASSESSOR'S MAP & LOT !,:::_INSTALLER'S NAME&PHONE NO. 6D/��OG y�ll7�D�1cS?` �7/�✓T�9 • /Seo ;SEPTIC TANK CAPACITY s�C LEACHING FACILITY' (type)_F_w�L 31�rS �f (size) :/O/yo�X'?:- :f NO OF BEDROOMS ` ':B:UILDER O WNE /�&V3(�-�`/ ?E-WIT DATE: ,S_I COMPLIANCE.DATE: Z �- 9'7 Separation Distance Between the: )viazimum Adjusted Groundwater Table and Bottom of Leaching Facility. rf Feet `:P ate Water Supply Well and.Leaching.Facility (If any wells exist ::;;`On site or.within 200 feet leaching facility) �� Feet. >i >:8dge of Wetland-ind Leaching Facility(If any wetlands exist ` witivri 300 feet of leaching facility) �' Feet :A ':-Furnished by Rear . �. y1 iD by -4 4- /,, n No.......V_9!�.--- J Flzs. ....................... THE-COMMONWEALTH OF MASSACHUSETTS BOAR® HEALTH ........../ d)7 Z,0........ 0 F........:-01 - 7.4-4-1............................. Appliration for Utopnoal Vorko onslrurtion Vrrmff Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System a 1, ........... .......a........... F,.�:�� .... .... s -or Lo -go--)-Addres - ---------------------- ----..z .1 �.------------. . .Wit . ner Address W ---------- c�� _ ._.. ... = ---------------- y- ............................................... Installer.— Address Q Type of Building ;. Size Lot..z./,._5??......Sq. feet U Dwelling—No. of Bedrooms-----------lel/.,............... .Expansion Attic ( ) Garbage Grinder ( ) pi Other—Type of Building ---WA Ad No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures,.1___ ' w Design. Flow.................) _ ....SJ..__.�..._-_.p, -gallons per person per day. Total daily flow.................. _--�............gallons. WSeptic Tank-�Liquid capacity-!�!�.'_gallons Length................ Width---------------- Diameter•----__-___-___ Depth-------------._ x Disposal Trench—No..................... Width___-_._____. _ __ T to/Le!n -h----.______ = Total leaching area-------- _____.____sq. ft. 3 Seepage Pit No.___ .._.._... Diameter/ ... Dept brlow ihlet____. __._.__._ Total leaching area__6__Z__jKsq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water___-_--._.---.---_-.---- fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_---____________-___---. Q'+ ------- ' --r 1. Descri Description of S i;.� � ' 't � -_- - -- --- - P ' f 2 G 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place_,the system in operation until a Certificate of Compliance has b en issued by e and of health. I Slgn dY A lication A' roved B � PP PP Y 40 Date ../ ' Application Disapproved for the following reasons:................................................................................................................ Date Permit No.......................................................... Issued.._..;I—e ---------- `TPAWAW 1 i No....... ............... .................... THE COMMONWEALTH OF MASSACHUSET 4V.;,, BOAR® OF HEALTH OF...... r ... pan for R .iliac 101ir Tomtrurtion Prrmit Application is hereby made for a Permit to Construct ( ) Repair ( ) a ividual Sewa e Disposal Syst .._ P .. __. .•..•.... ......... ....».. �... _-__»-:_ .__ ! `} } Location Address a 1 c or Lot Not Owner �h dr s -. i r q Ad es W ... ....r + Installer 4 Address UType of Building Size Lot_ 1 ......Sq. feet Dwelling No. of Bedrooms............................................" Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Buildin ¢ rl ..... No. of crsons_____________•.___- __ Showers — Cafeteria a YP g == = P' ( ) ( ) Otherfixtures..... ----- -------•-••••••-•••-••--••--•--•----••••--••--•'--'----•--......----•---••••••---........... Design Flow..................4„ ..__ gallons per person per day. Total daily flow................... , �-'__---_-gallons. WSeptic Tank /Liquid capacity 6 gallons Length`__,•_ __-____ Width---------------- Diameter-_-_-_ Depth-. -_-.---.--. _ x Disposal Trench No _-.,____- Width-- ,tal engt 4 Total leaching area.................. sq. ft. Seepage Pit No '.�............. Diameter/4.. `____ epth bolo i et......_ ; __.•_ Total leaching area___ _ -sq. ft. Z Other Distribution box ( ) Dosing tank ( ) t a Percolation Test Results Performed by:........................................................1--------------- 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-__--___--_--_--__-- - Description of S �" P.� '' _? __'___ v . ...° -- - ---- ---------- _p________ ____________________________________ ___ _________ ___________ `l -------------------------------------------------------°______________ _____.....•..._.____...__.._._....._...•_.__._______._.._____...._._........._._----____________-------__-_-----_•-_____-__•--__ h+Ti �.. U Nature of Repairs or Alterations—A saver when applicable------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ........................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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 --------- -^ «_ s { • �` ...<..,��...� � Applicatton Approved By.... "" s a r Application Disapproved for the following reasons-..................... - ------------------------------------------- --------- ------- ---------- ..----------•---•--------------------------------•------------•---•---•------•--'------------•--____-------------------------------------------------------------------------------------------------- Date PermitNo........-•-•.................'---- .....:..;........... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH Tr tifiratr of aaftphatirr TV ISS _ 0 C TIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by..... ----•--------- - / { ,installer ------------------------------------ has been installers incco�a�Clance width r-dvir XI of Stcr e as described in the application for Disposal Works Constructio i Permit I`?o___________________,�•______............: dated.___.._... -___.____--_•-________ r.., __pp THE ISSUANCE OF THIS CERTIFICATE SHALL N0163ftONSTRUED AS A Rio 'PEaHAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...........................•---------•-------------............................ --...........---------_... Inspector.--------=-------------------------------------------"--- ......................... THE COMMONWEALTH. OF MASSACHUSETTS- 4. BOARD OF HEALTH OF.. No.. �, .. FEE_ .. �°. Permission is hereby granted_ k- --- ° . to Constr or Repair. ( an n'dlvidual'ecvage .W10 System { at - ---- ,.+��,.,�=•'sIt'�t'�'!^ :.y as shown on the application for Disposal Works Construction Pnit No Dated . „an•� .{f� ,.®." oN,' -____ _ -•• - .................» DATE.......... -------_ ---- ' . .............. FORM . 1255 HOBBS & WARREN. INC.. PUBLISHERS