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Home My WebLink About1040 MAIN ST./RTE 6A(W.BARN.) - Health 1040 MAIN ST./RT. 6A, W. BARNSTABLE A =178 008 e � e I 0 0 0 I e o e e TON B STABLE LOCATION LA I SEWAGE # VILLAGE �� b�-�ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ,,(\ SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER 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 I n site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If an we ands exist within 300 feet of leaching facility) Feet Furnished by �� AA h��IG FA I� 6 3� cc ,y` f TOXIC AND HAZARDOUS MATERIALS R STRATION FORM NAME OF BUSINESS: l .L. kzc ' LO-A& DA �fb 1 Mail To: BUSINESS LOCATION: ® Board of Health MAILING ADDRESS: �.v. 1 Town of Barnstable P.O. Box 534 TELEPHONE NUMBER: 17?_)Z �CQ2 13ZJ Hyannis, MA 02601 CONTACT PERSON: -A)jLX I [a )Q _ EMERGENCY CONTACT TELEPHONE NUMBER: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO_1�k 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) Rustp roofers 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) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business 17r _ THE COMMONWEALTH OF MASSACHUSETTS BOAFRD OF HEALTH TO*N OF Appliration for DinVviittl Works C> onotrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: .... . ..VZ._..._ ..� G% r•-• - ---.--- ` �... •- ................ i Loc ion-Addre or Lot No. ----------------- ...................................._ ..... ....fn ..........ner Addr .. . ..�.... ...... .....�. ' ...�.�.................. �'. ............... . ............. nstaller Address Typ of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..... .Expansion Attic ( ) Garbage Grinder ( ) �+ ` Other—Type T e of Building . No. of persons..................... p., YP g ••--------------•------.... P •------ Showers ( ) — Cafeteria ( ) - a' 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. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area....._............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) PercolationTest Results Performed by.... ••---••....:.........•-•••••....._........................................................ Date........................................ aTest 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........................ ........................................ •------------------------ ••... •-------------- -------------- ------- .-_-.... -------- -------------------- -............. 0 Description of Soil......................•--•------.._.....------------.............................---•-----------------•---------------••----•-••---...................................... x W ••••••••............................•--••--••••--••-•----- ---•••--•--------••-•-••......•• ----••----•• --- ---•---- --........_.. ...... ....... UNature of Repairs or Alterat�s—AnsiYer when ap licable._.__ :. . ..................................•------- -t� / ` Agreement: The undersigned agrees to install the aforedescribed Tndividual Sewage Disposal System in accordance with the provisions of i1Til', 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been y✓v cd t-by ?? Signed..-- --- •- --- ...............g... .........................:....... ... Date Application Approved By.................. •--•. Date Application Disapproved for the following reasons:.............................................................................................................. .........................................................•---.....------......--•----•----...............•-••••---•••••••••-•••••••••-•••••••••......••••-•---••...•••••-••••••-•••••-•---•--••------•-- Date Permit No........... _ _ .�.�-----•-••----._.. Issued..------..,�...°-.-.�.�..�. :-�•✓--•-•---...._. Date t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF �6C.� Appliration for Diopoottl Workri Toni#rnr#ion Prrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: � _ ......1o�f ..---�. � -•-•- ..........................._._...-...... Loc�pion-Add re - �A ..----. �—�✓ - or Lot No. ............................. . Imo. �. -..... • caner, acre staller Address T of Buildin Size Lot...........................Sq. feet g Dwelling— No. of Bedrooms-.....-, ................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •-----•-------------------------------------------••---•••••---..._._......................--•••-•...........---------........-••-•.:. O. Description of Soil....................................................................................•------•----....-----------.....--------....---------._..-..._.............._••_---- x w ----------------------------------------------•---...----------------------------------••---------._...--------• -- ......... ------ -----•---------.. .................... U Nature of Repairs or Alterations—Answer when ap licable... - ---- -- .. ..... �.......�4._,!�r .. �.�� r� ...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'IILE� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ssued by the board of health. Signed..... .... ..... . ............................... Date Application Approved By................. ... ..... - .._...._•----•---....�. ...... l . "-�•' � sate Application Disapproved for the f o wing reasons:.............................................................................................................. ------------------------------------`^--------------------._....�.----------------••------•----------...-----------...........-----...-_.......__....---------.-..__..._....--•- .... Da-t-e.. . Permit ...................... Issued.. .__......:.. .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of YARMOUTH Trr#ifiratr of Tomplinnrr Te-4 TO ERTIY, That Individual Sewage Disposal System constructed ( ) .or Repairedby-1. �: ...............•---.......------------................._•-•-•--•.....- ��_ / I�staller ati -Lv -------- - .............................................................. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary 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....................................................•---•.............••-•-•--.. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of YARMOUTH < // ........._.. FEE.- 0............ Ropo I Works Tons nr#ion f rrmit Permission is hereby granted_.: !� �s4� - ... .Cl "_.,��' l "t'.......................................... .... to Contrru1ct ( ) or Repair ( n In vtdual S= ,age Disposal S ��tem at No..1Q'l 11i_-- ----------��.......:!�J�,1.. ��. ............................... f Street G r as shown on the application for Disposal Works Construction Perini or� _____________ Dated. _-:-.:5?12 .1.. ............. .................... ..--.�� ........ ........ .................... . -�. lloanl of Health DATE------_..�....... ................................. Conunonwealth of Massachusetts Executive Office of Envirolunental Affairs Dept. of Environmental Protection ad One winter Street'Boston,Ma. 02108 John Gtpti D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 1040 Rt,6AWest Barnstable I` Address of Owner: Date of Inspection: 8124198 (If different) Name of Inspector: John Graci Donati:P.O.Box 342 West Barnstable 02668 1 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 Passes 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 lmply any warranty or guarantee of the longevity ofthe F81Is septic system and any of Its components useful life. Inspector's Signature: Date: 8124= The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)daysof completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector anti the system ne II submit the report to the appropriate regional office of the Department of Environmental Protection. ��} 4 The oriainal should be sent to the system owner and copies sent to the buyer,if applicable and the appr (ring,authority.^ 1 RECEIVEO INSPECTION SUMMARY: AUG s 1 1998 Check A. B. C,or D: TOWN OFBARNSTABLE A] SYSTEM PASSES: NEAIIHDEPi x I have not found any information which indicates that the system violates any of the failure criteria 4 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 — 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 conforming septic tank as approved by the Board of Health. (revised 04127197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1040 Rt.SA West Barnstable Owner: Donati:P.O.Box 342 West Bamstable 02668 Date of Inspection:8124198 — Sew.acte 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 CJ 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 04r27197) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1040 Rt.6A West Barnstable Owner: Donati:P.O.Box 342 West Barnstable 02668 Date of Inspection:8124198 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). Plumbers 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 must 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 II 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. (revlaed 04R7197) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 1040 Rt.6A West Barnstable Owner: Donati:P.O.Box 342 West Barnstable 02668 Date of Inspection:8124198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: ,t_ — 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. _t_ — 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, 9 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)] i (revised OV27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1040 Rt.0A West Barnstable Owner: Donau:P.O.Box 342 West Barnstable 02668 Date of Inspection:8/24199 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g•P•d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: 3 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: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nra 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: nra OTHER: (Describe) nra Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: rda TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Uverflow 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: New System was Installed 4 years ago. Sewaue odors detected when arriving at the site: (yes or no) No (revised 04:27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1040 Rt.6A West Barnstable Owner: Donati:P.O.Box 342 West Barnstable 02668 Date of Inspection:8124198 SEPTIC TANK: x (locate on site plan) Depth below grade: 3' Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank.is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L10V*H57"w10'H20 Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:s" Distance form bottom of scum to bottom of outlet tee or baffle: 15" How d!mensions 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 and functioning properly.Recommend pumping every two years. GREASE TRAP:_ (locate on site plan) Depth below grade: rva 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:nra Distance from bottom of scum to bottom of outlet tee or baffle:nra Date of last pumpingnra 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.) We BUILDING SEWER: (Locate on site plan) Depth below grade: TV Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line?00+rromwell Diameter: 4"_ Qimments: (conditions of joints,venting,evidence of leakage,etc.) (rev19ed 04,Q7197) . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1040 Rt.0A West Barnstable Owner: Donau:P.O.Box 342 West Barnstable 02888 Date of Inspection:8124198 TIGHT OR HOLDING TANK: (locate on site plan) Deptl• below grade: n!a Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nra Capacity: nia gallons Design flow- rva gallons/day Alarm ievel:_nfa Alarm in working order?_Yes_No Date of previous pumping: Comrents: (condition of inlet tee,condition of alarm and float switches,etc.) Ne DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: liquid level with bottom of pipe Comments: (note it level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) D$ox is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in•.corking order.(yes or no)No Alarms ir, working order(yes or no)_Ye: Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) rda (revised 04.217197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 1040Rt.OA West Barnstable Ow n e r: Donati:P.O.Box 342 West Barnstable 02888 Date of Inspection:9124198 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: n1a Type leaching pits, number: rya leaching chambers, number:n1a leaching galleries,number: four leaching galleries leaching trenches, number,length: rda leaching fields, number, dimensions:nla overt low cesspocl, number:n1a Alternate system: rda Name of Technology:_n1a Comnitei ts: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Syster,and all components are structurally sound and runetioning properly. CESSPOOLS: (locate on site plan) Numtr:r and configuration: n1a DeptP-fop of liquid to inlet invert: n1a Dep:r _-f solids layer: n1a Depth .,f ,cum layer: rda Dime ,:,Ions of cesspool: n1a Mates;-:ls of construction: n1a Indicr;. -i of groundwater: n1a nflo�v(cesspool must be pumped as part of inspection) rda Comrn--nis: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda PRIVY:_ (locate on site plan) Matem-jfc,of construction: aUa Dimensions: n1a Deptl .,I solids: rua Comm-:rits: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) rds SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1040 Rt.6A West Barnstable Donati:P.O.Box 342 West Barnstable 02668 8124199 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) rA AA fl c cc co (revised 1)VrT971 Page ! of 10 N r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1040 RL GA West Barnstable Donau:P.O.Box 342 West Barnstable 02668 9124199 Depth of groundwater 12 i-cease 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 Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) l GS maps end charts (rnYlted 0 V27i97) page I0 of 10 a R TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS V Y ASSESSORS MAP NO. fir( PARCEL NO. ap$ ADDRESS; Iba e�A� VILLAGES NAME;._.. _�QYYLF5 ��'.� ..PC i '�} f'L -.-- CONTACT PERSON rj�oL PHONE NUMBER 36A-377 6 LOCATION OF TANKS: . CAPACITY: TYPE OF- FUEL. AGE: TYPE: LEAK OR CHEMICAL: n DETECTION SYSTEM! Q L.LTS� � DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETT S OiW�tNG THE LOCATION OF TANKS ON THE BACK OF THIS CARD., s f. , r 4 4 Wp „ of .0 ate 4135�( Ile �{ � P*; 0- aox- 534 Hy.ai,n 5 14A 0 601 f REM{ Underground 'task at4 . 1 MAIN STREET . R � �s ,. The SarnstabLe neattlh -p�r "A 0.44 ca tora K :, ea'a�t��e^ r�auno n or fuet (or i ct aar�: + 7� C a t e t an du C a � £ to.ra. 4y�rtems,. You are_. direct + to. tta. ve 4h.. .ask. Ott pipIng, '.eltt dwi h i n.. thirty. (3 � ays . r -no, t �SiltS You a:r4 reto 1n ed that you i#h ai(. have the ��t�� .and � �� .p50iri t :sted .durw�Ing ��-rye l0thJ 13th, 15t..h . ` l th and. 1'9t� y��'� a '.te#~ x'1�tattit:`3c�Ar� at�+Ci' AY."�Y�ld.a�:�:�' the;-'eafte�` r cg c st a 1arI-mg, � tte 0 t� r d t r ► t , i.. w BARN TABLE 0240 ` TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE CWe ASSESSOR'S MAP & LOT j]S INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY / LEACHING FACILITY:(type) (size) S%ryxq NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER � yi�' �- //y , // DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No (/ 30 U VV N--Vt`t3AHN6 rAb-L1L � j ,rr,�,q,� PrintRody shopsBOARD OF HEALTIOsatisractgry j31L Auto Ounsatisfactory- 4. Manufacturers COMPANY ,/` /� -'✓ (see"Orders") S. Reta#.1 Stores I ff 6. Fuel, Suppliers ADDRESS r ' � i ( (A Ai -4 Class: 7. Misc llanevus 7�fT �� i UAN1•ITIES AND STORAGE (IN'-indoors; OUf=outdoo ``Lys=��' A ' Case lots Drums AboveTanks Underground Tanks MAJOR'FfAT6`R1�At: ' IN OUT I I R 6 gall I lops o f Fuels: A. Gasoline, Jet Fuel (A) Diesel, Kerosene, 12 (B) Heavy Oils: — ± waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers _ 1�A1'lr4.�,�5��^''.�Fitt��.,•r.-..,tea �,.i�i-f�� 'r-��'f,/��•.' "-"v I j` U . ! L V 3 . Miscellaneous: ' DISPOSAL/RECLAVATION REhu•RKS• K - 1. Sanitary Sewage 2. Water Supply - f k/ 1-114*1 OTown Sewer public ` _ On-site Private r 3. Indoor Floor Drains: YES NO Q Holding tank t , MUC OCatch basin/Dry well _..._...._ ..___._. ._._. On-site system `UitI3E1t ti _ -" __ � n ¢ 4. Outdoor Surface drains:YES NO Q Holding. tank: MUC 10 Catch,,basin/Dry .well a OOn-si'te 4sy stem S.""Was'!�e Tfansporte Licensed? mesLf_Hauler_ „lie-itInation, Waste Prod uc - YF ' I ti�•� s X A- 4 (LIV A eis .erview f6spector Date