HomeMy WebLinkAbout0266 CARRIAGE LANE - Health (2) /s xy.z.. aex ter.;,.�.a�;�. •rc. w.: .. _.....r........ �
I
-- 66 Carriage Lane
Barnstable
• 1 •
YOU WISH TO OPEN A BUSINESS? 12,(o (p
For Your Information: Business certificates (cost$40,00 for,4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signaturc:>.5 on this form at ?Q0 Main 5t:,
Take the completed form to the Town Clerk's Office, 1st FI., >`-1:rin St., Hyannis, Mrs 02601 (.Town Hall) and get the Business Certificate that is
required by law.
DATE: C Fill in please:
r APPLICANT'S YOUR NAME/S: �..�
er
x BUSINESS YOUR HOME ADDRE�
' TELEPHONE # Home Telephone Number h 'lU
NAME.OF CORPORATION: -7-OCAf
NAME OF NEW BUSINESS PIE OF BUSINESS (i l t✓J � .J
IS THIS A HO%ME OCCUPATION? YES _ NO Q p�
°� `' �' _(Assessing)
,t �I1�XP/PARCEL NUMBER L 1
ADDRESS.OF BUSINESS 1
In o
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 �0'W l y�
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 has een jnf of the permit requirements that pertain to this type of business.
�
S� re*
COMMENTS: Q Z e natu * '
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)This individual has beeChfor 'rOf the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
r .
r .
:. Commonwealth of Massachusetts
Title 5 Official inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 Carria b9 e Lane
Property Address
Richard Pinkowitz .
Owner Owner's Name
information is Barnstable MA 02630 08/17/12'
required for every
page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
or the cclnptfter, _
use only the tab 1. Inspector:
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
sy Company Name
PO'BOX 896
Company Address
East Dennis MA 02641
Cityfrown state Zip Code
508-385-7608 Sl 3742
Telephone Number Ucense Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes . - ❑ Conditionally Passes ❑. Fails
❑ Needs Further.Evaluation by the Local Approving Authority
/C } I //V/w 08/17112
Inspecto s Signature t Date
e
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection.If the system is a shared'system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall'submit the
report to the appropriate regional office of the DEP The original should be sent to the system owner
and copies sent to the buyer,if applicable,and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
I
t5ins•11110 Tr a Inspection form:Sutp. a Se1.1isposal System•gage 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's.Name
information is required for every Barnstable MA 02630 08/17/12
page CityrFown state Zip Code Date of Inspection
B. Certification (cont;)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined"(Y,N, ND)for the following statements.If"not
determined,"please explain.
The septic tank is metal and over 20'years old"or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•11110 Title 5Official Inspection Form:Subsurface Sewage Disposal'System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's Name
information is Barnstable MA 02630 08/17/12
requiredd for every
page. Citylrown State Zip Code Dateof Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced, ❑ Y Q U ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.-
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a mannerwhich will protect public health,
safety and the environment:
El 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
!VriB i ii i u Twe 5 vi1.:ifii hnspieEtorii Funm Subsumes Swwage Mposal System-Page 3 0117
Commonwealth of Massachusetts
.Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r
lug 266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 08/t7/12
page. City/Town State :Zip Code Date of inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public,health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and.SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and.SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
"*This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal
coliform bacteria indicates,absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes.' or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground orsur%ce waters
due to an overloaded or clogged:SAS or cesspool-
0 ® Static liquid level in the distribution box above outlet.invert due to an overloaded
or clogged SAS orcesspoot
I El ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
ei
Commonwealth of Massachusetts
NEW
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 09/17/12;
page. City/Town State Zip Code Date of inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or
obstructed pipe(s).Number of times pumped:.
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a,cesspool or privy is within a Zone 1 of a public well.
❑ ®: Any portion of a cesspool or privy is within.50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal colNorm bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody,must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the.system,fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following„in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead.Protection
Area—IWPA)or a mapped Zone 11 of'a public water supply well
)f you have answered'yes"to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has faded.The owner or operator of any large
system considered a significant threat under Section E or faded under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department
t5ins•11/10 Titles Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora.
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 08/1711:2`
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have,large volumes of water been introduced to the:system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding,the SAS,located on site?
S . ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
El Was the facility owner(and occupants if different from owner)provided with
® information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information.For example,a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
r
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 Carriage Lane
Property Address,
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 08/17/12
page. C4/'rbwn state Zip Code Date:of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings,if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑' Yes ® No
10/11
Last date of occupancy: Date Dade
CommerciaUlndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
t5ins-11/10 Title 5Offcial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 08/171112
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
Generat Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box,soil absorption system
El Single cesspool
❑ Overflow cesspool
Privy
❑ Shared system(yes or no)(if yes,attach previous inspection.records,if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the UA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ - Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Fom
s Subsurface Sewage Disposal System Form-Notfor Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 08/17/12
page. Citylrown state Zip Code Date:of Inspection.
D. System Information, (cone.)
Approximate age of all components,date installed(if known)and source of information:
06/30/80 per BOH
Were sewage odors detected when an-iving at.the site? ❑ Yes No
Building Sewer(locate on site plan):
2.0
Depth below grade: et
feeet
Material of construction:
❑cast iron Z 40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet.
I
Comments(on condition of joints,venting,evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade: 2.5
P 9 feet
Material of construction:
®concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal,list age
years-
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1,000 gal
3„
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official inspection. Fora
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 08/17/12;
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29"
• 3,
Scum thickness
Distance from top of scum:to top of outlet tee or baffle 6-1
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap(locate on site plan): r
Depth below grade: feet
Material of construction:
❑concrete 0 metal 0 fiberglass 0 polyethylene: other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 08/17/12
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal El fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Trite 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's iNante
information is required for every Barnstable MA 02630 08/17/12'
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet'invert even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located',explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsufface Sewage Disposal System Force-Not for Voluntary Assessments
266 Carriage Lane
lug .1
Property Address
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 08/17/12
page. Cityfr own State Zip Code !:Tate of Inspection
D. System Information (cunt.).
Type:
®' leaching pits number:
t.
❑ leaching chambers number:
❑ Teaching galleries number:
❑ leaching trenches number,length:
leaching fields number.dimensions:.
❑ g ,
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.):
This system has a 6'x6'precast pit surrounded by a foot of stone.There was no sign of ponding or
failure.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Tdfe 5 Officia4Inspection Form:Subsurface Sewage Disposal System Page 13 of 17
f
Commonwealth of Massachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owners Name
information is Barnstable MA 02630 08/17/12
required for every
page. City/Town state Zip Code Date of Inspection
D. System Information (cont..)
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
Privylocate on site plan):
( P )
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
t
t5ins•11/10 Tate 5 Ofrwt Inspection Form:Subsurface.Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts �
'title 5 Official Inspection Form
Subsurface Sewage Disposal System l onn-Not for Vohmtary Assessments
266 Carriage lane
Property Address
Richard Pinkowitz.
owner owroreNane
information IsBarnstable MA 02630 08/f R2
reared for every page- CYRown State Zip Code Date of Inspection
D. System tnfbmwtion (coot)
Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,Including lies to
at least two permanent reference landmarks or benchmarks.Locate all wells wWh 100 feet Locate
where public water supply enters the building.Check one of boxes below:
® hand-sketch in the area below
❑ drawing attached separately
r
3Y
t ,
t5h�•11/10 Tite 6 OffbW trrepec&m Form:Sufsuftce Sewage Disposal Sydam•Pape 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�< 266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 08/17/12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cone.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting properly/observation:hole within 150 feet of SAS)
❑ Checked with local Board of Health:-explain:
❑ Checked with local excavators,installers (attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t51ns-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Notfor Voluntary Assessments
266 Carriage Lane
Property Address
Richard Pinkowitz
Owner Owner's Name
information is required for every Barnstable MA 02630 08/17/12
page. City/Town State Zip Code Date=of,Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B,C,D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15'or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Town of Barnstable
�•� Barnstable
Regulatory Services
BARNSTABL.E,
v MASS. Thomas F. Geiler, Director A"mericaOty
1639• ♦� , I
�tFD MA'1 A 1
Public Health Division 2007
Thomas McKean, Director
200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
August 14, 2012
266 Carriage Lane LLC RE: Underground Storage Tank,
11 Church Street 266 CARRIAGE LANE,
Newton, MA 02458-2015 BARNSTABLE
Map/Parcel: 297036
Tank Number: 1
Tag Number: 905
Dear Sir/Madame,
The Public Health Division(PHD) is in receipt of a copy of the tank removal Application and
Permit issued by the Barnstable Fire Department, and the "tank yard" receipt demonstrating that
the above referenced underground storage tank was removed on or about November 26, 2007.
The Public Health Division appreciates your response to the "ORDER TO REMOVE
UNDERGROUND TANK" and has updated its data base to reflect this underground storage
tank status change. Should you have any further questions'please contact Cynthia Martin of this
office at 508-862-4645.
Thomas A. McKean, RS, CHO
Health Agent
j co
Q:\Hazmat\Underground Tanks\266 Carriage Lane REMOVAL ACKNOWLEDGED 30 yr 2012.doe
Aug, 8 2012 3:25PM Vo 0305 P 1
PO Box 94 C3� IL Main Street J
Bamstable MA 02630
Phone: (508) 362-3312
Pax: (508)362-362-8444
Fax
To: Cynthia Marlin From: F.M.Pulslfer
Fax: 508-790-6304 Pages: 3
Phone:
Re: 266 Carriage Lane, Barnstable UST
Removal
❑Urgent ❑ For Review ❑Please Comment ❑Please Reply n Please Recycle
Please find attached a Copy of the UST removal for a 500 gal.UST at 266 Carriage Lane in Barnstable_
The tank was removed in 2007:
Please call with any questions.
Francis M.Puisifer
Deputy Fire Chief
608-362-3312
Aug 8 Z'c 12 3:25PM uo. 0305-^P, 2
Make application to local Fire Department.
Fire Department retains original application and issues duplicate as Permit.
APPLICATION and PERMIT Fee: `ZS:
for storage tank removal and transportation to approved tank disposal yard in accordance with the prov� isions
Of M.G.L. Chapter 148,Section 38A, 527 CMR 9.00, application is hereby made by:
• Iff
Tank Owner Name(please print) M1Uv1 L( A IAJ
// x
Address �/� rore yAp
swat �,
• stare �
•
Company Name ti(y
Fme Co,or Individual
Address (\.4 wt s nr
PM Address
Signature if r
aPMy3p r pe It)
,-r Signalure(If applying for permit)
O I Ceril ed Other CI IFCI Certiiled O LSP#y�
Other
Tank Location Co 67�1 1,
StWAddress �
Tank Capacity(gallons) ,53 e) -- A/Z) _Substance Last Stored 1
Tank Dimensions(diameter x length) '
Remarks:
Firm transporting waste Slate Lie,
Ha2ardous waste manifest# ERA-
Approved lank disposal'yard Tank yard#_ a-
Type of Inetl gas Tank yard address
01ly0r7own FDlD$ �` � >� � Permit#
Date of issue Dale of expiration
Dig safe approval number: �� ( (� Dig Sale Tofl Free Tel.Number-600-322-4844
Signature/Title of Officer granting permit
�ermovals)send Form FP 290R signed by Local Fire Qepl.to UST Regulatory Compliance Unil,One Ashburton Place,
Room 1310,Boston,MA 0210 1618,
FP_9A9 tmd�oa Waal � 'r A ltmu CAw_ Q,..A � 'l�
1
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sl
a
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REMOVEDRio = ...
PreTi C<stttenls W
or T
t. -
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- - affable -
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rank
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:Qw�erlOp&itoo s>oa�rrnsed:copy,ofIg0tifiC tics Fo�:9n9Clt-TP240R}to. USr.C_ompi sncc, ._..- ,..._.:,
Cease Stale Fire srsti P O:A 1Q25 State $tom MA-:-0177��
ld RL R,asd, .
k
' RECUT OF DLSPpSAt_OF lIl�ERBROUND STEEL STORAGE TANK
- rix-rr 291
NAME AND ADDRESS OF APPROVED TANK YARD -- i mmeS G7 Gm at Co,, Im
29 Wolcott SL
ReadviUc,MA 02137
APPROVED TANK.YARD NO_ fJG Tgrrk.Yard l eldpet 502 Chat-3.03[4)Nam�ber - O A0 S :s�2 t �7_Q
��urger l � of law I have personally exurrimW the undeig ound steel atoraee twrdt del vered m itas Wpiwed tank yard"by firth.mporabon or. o
0
nnhiP and ac®ytad Same ur eaYorrrrariaa+Wlh I I ChussusFFe P.sM, on ReOulalbn 502
5
Cl41R 3.00 for lM�er9ro�nd gEae1. Tank ds, tlinp yards. A NdW peme vm ivmo by:LOCAL Head of Far Depiartinent.
FDID41 '(� to barmpart tha'link>a tt"yard -
Name oral tank yard owner er owner—arrNior�sld ropreeeritative
� .. . .. -
SIGNATURE_: ,... :. -.:': .TrrLE'.-•; '... ... DATE Slc#D
This siprie d receipt of Cispaeal must be-tattrrned to the Lod Bead of Sre ixe.departnbnt FI)iOiEf f ] 7 p� z"d to 502 CMR 3.00_-
,:_ -
EAC H TANK MUST HAVE A IRE
CEIFT.OF OSSPOSAI
s. _ _ _
i
c�op�
oFt"E, Town of Barnstable
do
Regulatory Services- Barnstable
�
+ MMSI'ABLE, * AM-America city
Mom• Thomas F. Geiler, Director
1639. A -
Public Health Division 2007
Thomas McKean, Director
200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
August 2, 2012
266 Carriage Lane LLC RE: Underground Storage Tank,
11 Church Street 266 CARRIAGE LANE,
Newton, MA 02458-2015 BARNSTABLE
Map/Parcel: 297036
Tank Number: 1
Tag Number: 905
ORDER TO REMOVE UNDERGROUND TANK
The Public Health Division (PHD)records indicate that a_five-hundred gallon underground
storage tank was installed at 266 Carriage Lane, Barnstable in 1982. (Enclosed for your review
are copies of the original tank registration.) The PHD does not have records verifying the
removal of this tank. This tank exceeds thirty years in age and shall be removed as required by
the Town of Barnstable Code Chapter 326, Section 3, Fuel and Chemical Storage Tanks.
Therefore, you are ordered to remove this tank within sixty (60) days from the date of this
notice.
Upon completion of the tank removal and within ninety (90) days of receipt of this notice,
please submit to this office a copy of the permit for storage tank removal issued by your local
Fire Department. This permit is required to be obtained prior to the tank removal. This copy of
the removal permit serves as documentation that the underground storage tank was properly
removed and disposed of.
Should you be unaware of the existence of the above mentioned tank or its possible previous
removal, an independent third party (i.e. oil company, tank removal company, or environmental
services company) may be able to assist you in physically locating and/or verifying the current
existence of the tank. You can also contact your local Fire Department for a possible historical
record of the storage tank removal permit.
QAHazmaAUnderground Tankst66 Carriage Lane 30 yr 2012.doc
t
Should you be unable to provide a copy of a Fire Department tank removal permit, a written
document from an independent third party is required within ninety (90)days of receipt of this
notice as verification that the tank had been previously removed and/or does not exist.
You may request a hearing provided that a written petition requesting same is received by the
Board of Health within ten(10) days after this order is served.
Per Order of the Board of Health
Thomas A. McKean, PS, CHO
Health Agent
Enclosure: Underground Fuel and Chemical Storage Registration
QAHazmat\Underground Tanks\266 Carriage Lane 30 yr 2012.doc
TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
MAP NO. PARCEL .N0.
ADDRESS OF TANK: V-ILLAGE:
Lien ko� opft
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE':
! OWNER NAMEc \
PHONE:
INSTALLATION DATE: BY:
INSTALLER ADDRESS: .'CERT.1-40.
*TANK LOCATION:
.may,, (DCDCFiSnC YANK L-00AYXON
wxrH mummuc-r TO muXL—JDXN=
CAPACITY
TYPE OF TANK AGE FUEL/CHEMICAL
TESTING CERTIFICATION I I PASS [. I FAIL DATE
. LEAK DETECTION C I CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION C J YES NO , DATE TO BE REMOVED >1,
FIRE DEPT. PERMIT ISSUED C I YES. NO DATE
CONSERVATION I CHECK IF N/A DATE
BOARD OF HEALTH TAG NO.
I DATE.
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CAR
TOWN OF BARNSTABLE
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
ASSESSORS MAP NO. PARCEL NO.
Ill
ADDRESS,' — VILLAGE /x
,"
NAME'
CONTACT PERSON
PHONE NUMBER
LOCATIONIOF TANKS' CAPACITY: TYPE OF FUEL AGE: TYPE:
LEAK
OR CHEMICAL: DETECTION
SYSTEM!
Li
DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5.
DATE G.F- FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED
DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD.
SID b
LOCATION �� �k SEWAGE PERMIT NO.
VIVA
Ik INSTALLER'S NAME i ADDRESS
oh X) J L/ ASS SSORS MAE NOR17
Q yU PARCEL NO:�
�i a L f I h
R U I L D E R OR OWNER
oh `u Sim uLL Ir .nv.
DATE PERMIT ISSUED 9- 6;,
- ') 9 .
DATE COMPLIANCE ISSUED / V30epo
mAw ors Figm.6?M CARAGC
O � �
J'� d
�1
N .... ` /0:... Fps.......... ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_v.bt9 .............OF.......I � c... 7i --------------------------------------
Appliratiun for Dwpos al World Toustrurtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ()) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
W ..:.... __. . . ✓ s4 `fA._ 19/�/Z .. I�._.r.d�. Alnit �°[�R:f'.-
Owner s Address
s_.................................... ...�2.4.. .al ,_L..LAwa. 13q--Kn aTA- _aL ................
Installer Address
Q Type of Building Size Lot- � .....Sq. feet ,-
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures .----•--•--•--- --•---•---•---• -
W
Design Flow..............1f_A.....................gallons per person per day. Total daily flow.......-S.3®____._.__............._gallons.
04 Septic Tank—Liquid capacity_/PPt __gallons Length------ Width----47`..... Diameter________________ Depth...s�........
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-------'._�_.......sq. ft.
Seepage Pit No.....1'------------- Diameter...._._�a.` Depth below i et... __� ..... Total leaching area..V.?.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) �PY �L�W— -�� 7�
Percolation Test Results Performed b t�n'�___�-._ _.._.___. _ �.............. Date.__.______. .._ �..
W Y---- ---- - ���:'��.-•-••--yam•- -- �---•r---------•--
a Test Pit No. I.._.o�-f__minutes per inch Depth of Test Pit._l' ' .___.. Depth to ground water.,Y10 , t_"-fVX&a
Test Pit No. 2................minutes per inch Depth of Test Pit___ ... Depth to ground water_lanse�C v�l'
p4 •-••----••---------------------•-•----•-••......••• --•-•-••-••••--••••••-••...........--•-••-
O Description of Soil... ..... AT-1..... c • 5�e - .��✓ -.�... .
U 9-.�=L ..... �' n.3 ............................... /�rJf-
....... ............'-� �D. -•----------------- - -- - --�.....:..----
W --------•--------------------------------------------------------------------,------ ---•-•--••••--••------•----•------......-•----------........----••------------•-•-•---------•-•--•-••-....--•••••.•.
UNature of Repairs or Alterations—Answer when applicable.-______________________________________________________________________________________________
••-•••--•••-•-------------•------••-----•-••--••-••----•••---•--•-•-••-••••-••-••-•-•.............---•••....•---------------------•-------•-•••---•---•-----------•••--•-•-•--•--•-•---•-••-••••••-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT_1Z 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. q
Sign .......................... -----------------------
D to
Application Approved BY--- . .. . c� /
Application Disapproved for the following reasons:----••--------••--•-•••--•--•••••-•-•-•-------•--------------------•--•--••••--•••----.........................
.........................................................................................................................................................................................................
Permit No......................................................... Issued_---"yam-••-�-® �.........a�.
Date
NOT --------•
................
r. THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. ........................OF...........................................
Appliration for Disposal Works Tons.trurtion Frrutit
Application is hereby b_y made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
--------------------- . ....... ..............................................i�;.Kw..........................................
,Locatio",Address or 0.
P -7
it....WA&
�2c.. ......... ............... D. RCI.Al�......1) ,..A). a;
..............
Owner% Address
.............................. >........ ......249 ..............
Installer Address
Type of Building Size Lot---F w/ A—�......... Sq. feet
..........
Dwelling—No. of Bedrooms............ 3.................:........Expansion Attic Garbage Grinder
Other—Type of Building ............................. NO. persons..........._.__._.__._...... Showers Cafeteria
0.1 Other fixtures ........................... ..............
------------------^--------------------------------------------------------------*------*.............
Design Flow........... ........... .._._gallons per person per day. Total daily flow........... -.C.;.........................gallons.
1:41 Septic Tank—Liquid capacit., Length----ef!�...... Width----s__'-... Diameter................ Depth---
Disposal Trench—No- -------------------- Width.................. Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No......./........ Diameter..... .... Depth below Tot 190• '0�119
t-/- *- , fr...��7m....sq. ft.
z Other Distribution box Dosing,tank (�k� k"t
"Al " 01
I Percolation Test Results Performed'by_7?-Av��.....46�� Ae.---.,Date... 15'7 9
.. ...... ------------ .............
k_1 - 7
'j Test Pit No. 1...4V _minutes per inch Depth of'Test Pit... ....... Depth to ound
gr
(T, Test Pit No. 2................minutes per inch"N ...th of Test Pit.../4� .. Depth to ground water.A/V-11 C
P4 ...........................................................................;................................................................................
0
Description of Soil-. _-4 t.lz.... ..40-.".20 .......... .........................
---- ............4�........ ...... ....... ... .. ...
S;of�--Z>. a6 111_1�-X-�Y4 W 10c;;A-1119-
............... ................................:;,......................... -------I---------------7.........Z' .....................................................
--------------------------------------------....................................................... .
-------------------------------------------------------
---------------------------------------------- iv.4
U Nature of Repairs 6r,Al,terations—Answer when applicable..---_-_--------------------------- ...........r�.................................................
-----------------------------------------------------------------------------------------------------..................................................................................................
Agreement%
The undersigned agrees to install the aforedescribed'Jndividual'Sewage Disposal System in accordance with
yk the provisions of L'I'IE 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.
ign ... ....... ............I--
.... 7y
Application Approved By......... r -.... ................. ....... ..
Application Disapproved for the following reasons:...............................................................................................................
.......................... .......................................................................................................................................................... .................
Date
Permit,No........................................................ Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
'j
BOARD 0:.F 6,H-19ALTH
.......... ... .....OF............. .. ...................
...41..................
Tntifiratr -of Toutpliattrr
TH T HL TO LBRTIF hat the Individual Sewage Disposal System,}constructed or Repaired
by........... .... .. ...... .......... .............................. ..... ... ---- ---------
0. ...........
. K all
at......... I. ...... ..... ...... .. . ... . ...
........
has be installed in"accordanc with the provisions of TI 5 of The State Sanitary Code as describrd in the
ap 47.plication for Disposal Works Construction Permit No........ ..... .............. dated------ !�1�7---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIO SATISFACTORY.
DATE................
�.. Inspector
or.............................. -------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ALTH,
.. ..................
. ........... ..........OF............... ..... .................... ........
N . ................ FEE........ ...........
;Disposal rhs (to trud
Permission il�erAl,,7 granted........... . ........... .
..%4 . , .........................................
7j
u;age
�y
Permis.
to ConstrucA, or 1� air an I_ a a e Dispos S... ......... ..
0.....
.2-E
em
�:!,f. ......... ...................... ............................................
at N Lw... .... cr�......
Street
as shown on the application for Disposal Works Construction Per N ted......
.. ....... ... .... .... . ----- ------------------------------
-020
Board of
DATE.... ................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
47
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37
ZZ,
I Ner—a& "9nOA BiYve� a.v LhsSuh►ED �/33�+y
CERTIFIED PLOT PLAN
LOCATION s ,BG
SCALE DATE
r•ti'� Y " PLAN REFERENCE 407 ¢�
•.Hl,�l't,."Ff� ..,,huh�
fr
'r x3 KIEU El
ey0 ;► s
t so
I CERTIFY THAT THE . .. . ...... . .. ......
SHOWN ON THIS P TED ON THE GROUND
LOT f+` AS SHOWN HER AT IT CONFORMS TO THE
SETBACK RE S OF THE TOWN OF
. . . . WHEN CONSTRUCTED.
DATE . . . . . .. . . . . . .
PETITIONER: BAiS�A�3 �.QSS�
REGISTERED LAND SURVEYOR
N59345
SH6z-r Z aF Z s• 4-2-7-s
YtJ 's'
L. . �zd• o0
TOP OF FOUNDATION
CONCRETE COVER
CONCRETE COVERS
•'� 4' CAST IRON
PIPE (OR 12��MAX. 4ORANGEBURG(OR EQUIV.) 12"MAX. •
EQUIV)— MIN. PIPE- MIN. LEACH
' PITCH 1/4"PER. PITCH 1/4'PER.FT PIT PRECAST
° J LEACHING
avw
EL../!' - INVERT INVERT n . e•`:' PIT OR
SEPTIC TANK / oy DIST. //37 w EQUIV.
o INVERT ELl.�. . . . . . BOX EL. > �
iDao.. .. GAL. INVERT - �a ,:•• ,
o; EL. /./¢�!�. INVERT `o v 0: .., 3/4 TO II/2
,39 W W
I ELl1., ./ a WASHED
r EL//3.... e. �� �: J�
W STONE
• , /�16
W DIA.
DIA.-
PROFI LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE U
SOIL LOG WITNESSED BY :
DATE !7/979 TIME���o�' A`'? P !G . ! BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 7111i Z .4' y�•P,.t; ENGINEER
ELEV. . !!7.•69 . . ELEV. .//S..So , r��/
,
&�m/vo/�D. �, eE Z's,
rrnr� .
Lo�,arr �0�"1
DESIGN DATA '
,2c 4Zv
e�,vh bias✓- yo NUMBER OF BEDROOMS 3
s�►..D G.,�sa*�D TOTAL ESTIMATED FLOW . . 33a GALLONS/DAY
72"Ae►+str BOTTOM LEACHING AREA 78��
. SQ.FT. /PIT
-- SIDE LEACHING AREA . . � `S`5.v SQ.FT./ PIT
GARBAGE DISPOSAL AREA INCREASE)
,5�4•+uD
TOTAL LEACHING AREA . .u7.o u SQ.FT
PERCOLATION RATE . . . . . .�^/�. . . MIN/INCH
LEACHING AREA PER PERCOLATION RATE SQ.FT.
N� .WATER ENCOUNTERED
NUMBER OF LEACHING PITS
APPROVED . . . . . . BOARD OF HEALTH
. Uf=S7DnlE' f�R PST_
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATE . . . . . . . THOMAS E.KELLEY CO.
AGENT OR INSPECTOR ENGINEERS—SURVEYORS
346 LONG POND DRIN E
_ SOUTH YARMOUTH,XL LSS. �'�H DFAf�s
Of►�4.fy 02664 �02� THOMAS
1-07- g EO KW� o ,2�1 N
-LEY �, '" ,
G�ST£R SS�ONALE��
PETITIONER . � - /y�SS I'�SUM(*