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Home My WebLink About0275 STONEY POINT ROAD - Health A27=5 STONEY POINTRBARNSTABLE 005337 . 0 A 1 4 9� C 6 l 1 TOWN OF BARNSTABLE - Z 7S S,`'o#eY,,y,�y1 fad CATION � SEWAGE # ILLAGE ASSESSOR'S MAP&LOT-2 31 enQ r INSTALLER'S NAME&PHONE°NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 2 J�D®��%TS (size) 6 IrILI / NO.OF BEDROOMS BUILDER OR OWNER L✓/ ��$ PERMITDATE: ( S�! COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility %Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 33 c I- ol , t G� r TOWN OF BARNSTABLE LOCATION O SEWAGE # �ITLLAG - d_ ASSEZ04, 'S S MAP& LOT �SAG� o � NAME&PHONE NO;2 ICIQ }Vi SEPTIC TANK CAPACITY z42 LEACHING FACILITY: (type (size) 1�7 O.gals, (c, NO.OF BEDROOMS BUILDER R PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �`� Feet Private Water Supply Well and Leaching Facility (If any wells exist ,�/ on site or within 200 feet of leaching facility) 1 �' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300�fee-t of ea hing rt) ft' Feet Furnished by U Gc �/.�* •-l 3 _� - SKr' 337-Al 5 No._/. ��✓. � Fx$... .. ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Di-nVitittl Workii Towitrurt"tun 11amit Application is hereby made for a Permit to Construct ( ) or Repair (p-6 an Individual Sewage Disposal System at: ..---`-�7�••-- STu... c....1y �U!....�'� �a,ab L uw1✓..1/�-Pl Ut yo -------- , ........ --- - -• -- •-- ------ -- ocation-Address, t No. � �✓C a , ( 4-I nJ �-7Cj �ti� pG t etd GV vvy�✓t q&v: . ................................................. ------......--••••-----------•--•----.....--•-••...i....... Own W- Address 7(� �13N �fl_ 'M Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms___________________ ____________________Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures w Design Flow................-�...._....................gallons per person per day. Total daily flow............._y.........................gallons. WSeptic Tank—Liquid capacitv�4q---gallons Length---------------- Width---------------. Diameter---I.,.......... 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. 1----------------minutes per inch Depth of Test Pit---------7.......... Depth to ground water...------------------- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-..__----_--__-----_--. 9 -----------------------------•......--•-••----------•-----•-----•---------------------•-----................................................................ 0 Description of Soil........................................................................................................................................................................ x U w UNature of Repairs or Alterations—Answer when applicable..__. qJ 7--___-- .......6A'XrrQ"j&---..__�__Fri ?.... / ---------------t!�'1.¢-fiQl 1.,1'..)---�._1�.+!�E^1i__._-------------- t.. /A1 Agreement: L f�''� c-roXA-tl�-10" R,-J �-�--7- s'z�N£ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s&ben issued y t board of health. / Signed -------- ----- 7/,S 6 -------------------- Application,Approved By 1 -----....._.... .. .. }� Dace Application Disapproved for the following reasons: ...................................... ------------------------------------------------------------------------------- __.... ---- ------- ell - Permit No. `✓.....--------------/......�................... Issued .........1 '—� Dace THE COMMONWEALTH OF MASSACHUSETTS 3� 7! ' BOARD OF HEALTH . ✓ ( U J TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTII That the Individual Sewage Disposal System constructed ( ) or Repaired Y ( ) 6 2:'-r-6 (-0 - -- G'�S 1 ,-7r all --------------- -- ---------------------------........_----------------------------------_ -------- er at ----------------------------- - .7 �S'T!/��J �a) ,�Ti --------:..._. :—-- vN 1 Q.J�Q........ .... _.. has been installed in accordance with the provisions of TITI.E 5 of Th St to E ironmental Code as described in the application for Disposal Works Construction Permit No. .. - ._. .... .... dated ..... !' 57 r� = THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------ - -C` ►--..::)---------------------------------..-......._ Inspector ........................... '' ----------------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS -3 ✓ 7` BOARD OF HEALTH -� TOWN OF BARNSTABLE FEE- No BigiDiia1 Permission is hereby granted--------------- :---------:_ - - - -...-------------------------.......... to Construct ( ) or Repair ('>.) an Individual Sewage Disposal System atNo. ----------- �"?-5` �-�-=J-�`-�--...;. -�/n/7r ._....�. w! ................................... Street � ,.....�... as shown on the application for Disposal Works Construction Permit N - Dated____ ''"....._-..�� -2.. Board of Health DATE-----------.�- . ............ --------------••-- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS - 33 7 ® _ No..f. ?."�L. � FIB$...::-�0._................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH V TOWN OF BARNSTABLE .r Appliratiou for Dbnp sal Works Towitrurthm Vanfit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ........................•---------•---------....--•---------------------------.,--...... ------•-----------------------------------------•••--•...-------•---------------------•--------•-- q Location-Address or Lot No. :a t-✓Z•_t_5_ ....L�/ C_tom I AJ 5 , tl -V��t1 12C i&)T• (� i ...(--V�,✓d M V! �- Owner,., Address .............................. '-.-7 �_- w Oft , a t.o �� N.3 /c v c_-, 7 u L.J 41�y lLf1. /►i1 r�cS ,.a -----•-•------ ------------•-c�--------------••---•-•---•--------- •-•--•-- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms___________________� -------------.------Expansion Attic ( ) Garbage Grinder ( ) A4 Other—Type of Building _____________________-_____ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ----------------------_------------------------- W Design Flow__________________5..�_-______________gallons per person per day. Total daily flow----__________`I`I d__________________gallons. Septic Tank—Liquid capacity A4�__.gallons Length________________ Width_.-------------- Diameter................ Depth................ W Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-----------________..................................................... Date........................................ .4 Test Pit No. I................minutes per inch Depth of Test Pit_-________________._ Depth to ground water_-_______-___________-_. (i Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 •-•-•---•--------------------•---------•---•-------•-----------•------------••-•----•--._...--------......................................................... 0 Description of Soil........................................................................................................................................................................ W UNature of Repairs or Alterations—Answer when applicable.----(z 4J1 E-_-____:% _�_ ......... .'� � �-� _... c--z �AA 0j E v�s(),,-. t r' � e_(A(ems. tZ ALE r��t r---E,4*Jt�.._....1L� ...!�lsA� Agreement: C �� R t-TS fu/LA4,-),�L?c Q is`>' q 1-7 s z evt. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issued t y t.," board of health. Signed ........../.. ------- ----------------------------- Application, / A roved B - -.- . .. _~' ... �.,'"" -- - _;7 PP Y " - Dare Application Disapproved for the following reasons: -------"----"--- ---------------" ------ .......... ................ ----------"-------"------------------------"----."--�"---------- ---------- Permit No. -v'_ .. _ Issued _-..-. '` `p.............. Date 9 10 r BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM — ---— --------------------- Address Prop �2�� GJ/ iOC�� mINN, 9 Date of Inspec} Map arcel Own 537 PART A — CHECKLIST CHECK IF THE FOLLOWING HAVE BEEN DONE: PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. //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 COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. ---'AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. _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 SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. //THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS, PART B — SYSTEM INFORMATION _ FLOW CONDITIONS RESIDENTIAL -- --------------..----- ------- — -- 3 No of Bedrooms �/_ No of Current Residents — _ Garbage Grinder yes Laundry Connected to System 14 _ _Seasonal Use NON RESIDENTIAL: _SCalculated flow WATER METER READINGS,IF AVAILABLE: Pumping Records and Source of Information: GALLONS 6 � _ SYSTEM PUMPED AS PART OF INSPECTION? //0 IF YES,VOLUME PUMPED = GALS Reason for Pumping: — TYPE OF SYSTEM: Septic tank/distribution box/soil absorption system Single Cesspool _ Overflow Cesspool _ Privy Shared system (if yes, attach previous inspection records, if any) Other(explain) ----- ------------------------- -- - --I-- -------- ---._of------------------ Approximate age of all components. Date I stalled;if known. Source of infor lion. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? — __ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: Depth below grade: /( Dimensions: , Material of construction: oncrete Metal - FRP Other} Sludge Depth Z Distance from to�)f s#ge to bottom of outlet tee or baffle Scum Thickness %/ Distance from Top of rSc)jpi to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffler Comments: DISTRIBUTION BOX: Cc.Y>l DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: S PUMP CHAMBER: Pum 's in working order? Comments: SOIL ABSORPTION SYSTEM (SAS): IF NOT PRESENT,EXPLAIN: TYPE: — K,00 /D/2 _ oL VIS Co ments: _ CESSPOOLS: Alo Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Alb Materials of construction Dimensions Depth of solids Comments: . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B.— SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES, LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' .\p O 1� Nq� ` DEPTH TO GROUNDWATER: / , DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: /' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - FAILURE CRITERIA (Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.) ./tr Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? /z' Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? / Within 100 feet of a surface water supply or tributary to a surface water supply? t w Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? i 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 col form bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS I COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC ZHA LTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS TED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. VE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop j 12e ` �',�/ �C Date of Inspec} arcel Own PART A — CHECKLIST CHECK IF THE FOLLOWING HAVE BEEN DONE: PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. i/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 COLUMES OF WATER HAVE NOT BE I ODUCED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IFTHEY ARE NOTAVAILAB N/A. 11 THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. Cb i/G/ /�► �� C/THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. Z o� N c� J. FALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. ,�p 4 NSPe�} a G--'1'HE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE C TANhV NSPECTED� FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEP LIQUID,DEPTH OF SLU E, DEPTH OF SCUM. 4-'THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXIST ING� I APPROXIMATED BY NON—INTRUSIVE METHODS. E FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL No of Bedrooms No of Current Residents Garbage Grinder 1 Z�s Laundry Connected to System /41-U Seasonal Use NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: Pumping Records and Source of Information: GALLONS SYSTEM PUMPED AS PART OF INSPECTION?IA IF YES,VOLUME PUMPED = GALS Reason for Pumping: TYPE OF STEM: Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes, attach previous inspection records, if any) Other(explain) Appro imate a e of all components. Date installed if known. Source of inform tion.. 10sk ;79s� /o s SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM c1 PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: Depth below grade: �i Dimensions: /0 S Material of construction: oncrete Metal FRP Other} Sludge Depth 1111 h Distance from top of sludge to bottom of outlet tee or baffle 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 Comments: cZ S:� c 2,5412 /K S DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: PUMP CHAMBER: Pumps in working order? Comments: SOIL ABSORPTION SYSTEM-(SAS): IF NOT PRESENT,EXPLAIN: TYPE: J� mgnlis /Coo CESSPOOLS: Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Materials of co struction Dimensions Depth of solids Comments: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES, LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' �- SXW 0 1 a� DEPTH TO GROUNDWATER: / DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART C - FAILURE CRITERIA (Indicate Y-yes N-no ND-not determined.Describe basis of determination.If"not determined",explain why not.) Backup of Sewage into Facility? I Discharge or ponding of effluent to the surface of the ground or surface waters? / Static liquid level in the districution box above outlet invert? Y Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? r _ Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? /i 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,amonia nitrogen and nitrate nitrogen. PART D - CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS:. 766 WAKEBY ROAD, MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 II CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED AREAS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT7HE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: 9 ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY r ,� M1; TOWN Or BARNSTABLE / j of UNDERGROUND.FUEL AND CHEMICAL STORAGE SYSTEMS ,a V v��_ TIN(5 ASSESSORS MAP N0. � PARCEL N0. 000 ADDRESS! VILLAGE 03 CONTACT PERSON PHONE NUMBER LOCATION OF TANKS: CAPACITY: TYPE OF FUEL. AGE: TYPE: LEAK til OR CHEMICAL: DETECTION SYSTEM DATE OF' PURCHASE OF. EACH: 1. 2. 3. 4. 5. DATE OF: FIRE DEPARTMENT PERMIT: 110 6 TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS- ON-- THE BACK OF THIS CARD. � � I 1 t i i jj � ��t t �` ..__ .� t �� i ;� � ----- I E 1 ! A * � i � i ' � �� i ~`�-- �:,,:. I