HomeMy WebLinkAbout0080 ANGUS WAY - Health $0 ekingus Way
Centerville
A = 251 056
No. 4210 1/3 ORA
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TOWN OF BARNSTABLE
BOARD OF HEALTH ��`� �®
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION i
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Date kI Y 10 Time: In Out
Owner c\� ��]%N G Tenant&gut 0 6 8giu 5 t iei vo4t
Address 61 CACL;-,-cm� Address go Am6uS MliY
MA
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities A
4. Water Supply ] l /
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities 7 mAiuj NVAJ-i;0MIPLJANT 09CSY
10. Curtailment of Service c.i�n3tyT f6m 5 IN
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural ;
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal „� D3 7 73
17. Temporary Housing
18. Driveway Width
19. Number of Tenants Observed Z S l 't vv ITS �in1���
PART 11 j3 FT i JSGIt) hS
37. Placarding of Condemned Dwelling; STpP-AC,C (No BCD)?-
Removal of Occupants; Demolition
Number of Bedrooms I Number of Vehicles Allow d max) J
Number of Persons Allowed (ma�x.)(�
Person(s) Interviewed� �'1 Inspector
If Public Building such as Store or Hotel/Motel specify here
i� � Town of Barnstable Barnstable
of r
a
Regulatory Services Department
13ARNSFABLE,
'"
n` Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 FAX: 508-790-6304 Thomas F.Geiler,Director
Thomas A.McKean,CHO
June 3, 2009
Stephen Stickells
67 Carlton Ave.
Brookline,MA 02601
RE: 80 Angus Way, Centerville
Assessors (251/056)
Dear Mr. Stickells,
As per our Discussion regarding the Board of Health Order letter dated May 19, 2009
I have enclosed a sample deed restriction document for you to complete restricting the
property to 4 bedrooms based on the capacity of the Septic System(permit# 2003-428). `
Please return a completed 4 bedroom deed restriction with proof of recording to this
office or if you prefer you may remove the 51h bedroom by combining two bedrooms into
one as described in the order.
Please contact me if I can be of any additional help with this matter.
Sincerely,
Jaime Cabot, R.S.
Health Inspector
Town of Barnstable
(508) 862-4651
f
�
SECTIONON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signet re
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse X ❑Addressee
so that we can return the card to you. eceiv by(Printed Name) C. Date of Delivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
D.14,diVvery address different from item 1? ❑Yes 1
1. Article Addressed to: S z1 Ater delivery address below: ❑No
IV
rz 00 <-L.i N , ' v� 3. Service Type
(�` rtifled Mail ❑Express Mail
Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑yes
2. Article Number r e,{ -- - —; • :; ,-----;;; ; —;
(Transferfrom service labeq' 7���' 3020 00�1 `3429` 8165
�i PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
I
UNITED STATES POSTAL SERVICE First-Cldss Mail
Postage&Fees Paid
USPS
'Permit No.G-10
I
° Sender: Please print your name, address, and ZIP+4 in this box •
I
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' OMN
Town of Barnstable
Health Division
200 Main Street
Hyannis,MA 02601
I ytyy
����►>>s�ilsl�ii�iiissislli�6111 sssllaisii11111is III IisIMA
Town of Barnstable Barnstable
Regulatory Services Department p
+ AARNSTABLE,
4639 Public Health Division
ooar i634��,�$ � m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 v Thomas A.McKean,CHO
CERTTIFIED MAIL 7007 3020 0001 3429 8165 "
May 19, 2009
Stephen Stickells
67 Carlton Ave.
Brookline, MA 02601
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 80 Angus Way, Centerville, was inspected
On April 10, 2009 by Jaime Cabot, R.S. Health Inspector for the Town of Barnstable.
This inspection was conducted on the basis of the rental registration in accordance with
Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.300 & 310 CMR 15.00—Title V. Septic system (permit#2003-428)
capacity is only for 4 bedrooms; 5 bedrooms observed.
105CMR 410.550- Extermination of Insects,Rodents and Skunks.
Evidence of rodent activity,mice droppings were observed in the kitchen draws.
You are directed to correct the violations listed above within thirty (30) days of your
receipt of this notice by removing the 51h bedroom by combining two bedrooms into
one room and applying for building permits to do the work. The extra bedroom can
be removed by constructing a five foot cased opening between two adjoining rooms.
The tenant is directed to take action to eliminate the rodent activity within twenty-
four (24) hours of receipt of this notice.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten(10) days after the date the order is served.
Non-compliance will result in a fine of$100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations,please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
ORDER;O HE BOARD OF HEALTH
<t7g-)OasA. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
1 TOWN OF BARNSTABLE
i
5 " , BOARD OF HEALTH
Gr ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date 1 (6 �0 Time: In /b,•GU Out �G•,�
Owner S T f PH I N S l i C.1c E t_c.S Tenant Q hi 4,Q LA. 9-N O-AA
C3��-�xi dZc P•
Address 2.1 LCZAr-%e. t(,' aA- Address 8o H US lnJ A
1220 3-� Ati�,,��Xik �o �•t'-I limitK(5 wa eE N'(1154-./t LLE MAr
G 2Ld 1
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply V TG w N
5. Hot Water Facilities 8 ¢.
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities ULA 10, 300
10. Curtailment of Service
,.. r--9 To tz-,0 o S
11. Space and Use C(,(;gTrA
12. Exits tzll
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
I C G � , i N •N A,c w S
15. Garbage and Rubbish Storage and Disposal Lo Ati /D• S
16. Sewage Disposal
17.Temporary Housing N
18. Driveway Width
19. Number of Tenants Observed
PART II
37. Placarding of Condemned Dwelling; %alA.L �M•t-t
Removal of Occupants; Demolition �-d G p
Number of Bedrooms — �Z
(2 ti3S[AVdIP � �� Number of Vehicles Allowed (max) .r
Number of Persons Allowed
Person(s) Interviewed �(a
G Inspector
F
If Public Building such as Store or Hotel/Motel specify here
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FORM 30 C&w HOBBS&WARREN'" THE COMMONWEALTH OF MASSACHUSETTS
• BOARD OF HE LTH
CITY/TOWN
W e
DEPARTMENT
ADDRESS
GSM Sv9 y`0� �
TELEP ONE I Q
Address b v" _ Occupants —
Floor Apartment No. No.of Occupants
No. of Habitable Rooms_h No.Sleeping Rooms
No.dwelling or rooming units No.Stories
Name and address of o er
Remarks Reg. Vio.
YARD Out Id s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation: 41
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.: '—
Hall, Floor,Wall,Ceilin :
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen. Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3 SU
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.:
Stacks, Flues,Ve ts,Safeties.-
Kitchen Facilities 6ig
tove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS HECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR (See Over)
"THIS INSPECTION REP T IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJ
INSPECTOR TITLE
1— � 2 -' a " 7jv A.M.
DATE TIME IN
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and we of the
occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any
defect which renders them inoperable.
3 An defect in the electrical plumbing or heating system which makes such system or an art thereof in violation of
( ) Y . P 9 9 Y Y YP
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
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FORM30 ^^ THE COMMONWEALTH OF MASSACHUSETTS
��l W J HOBBS&w�RREN
` BOARD OF ALTH
CIR
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o DEPARTMENT
�'` _ I b�rro v
ADDRESS
M 0 e
NN Iq TELEPHONE l(p 1
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Address ------ -- --------Occupant--- -
Floor Apartment No. No.of Occupants---
No. of Habitable Rooms 4— No.Sleeping Rooms__'__,___ _—
No. dwelling or rooming units_____' No.Stories =
Name and address of own 4,.Y � ll�"
Remarks Reg. Vio.
YARD Out Bld s.: Fences: 0� Ljqfo
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room cl ,
Bedroom 1 p
Bedroom 2
Bedroom 3 � A °
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: V1
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin, Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT/4P SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY."
INSPECTOR- TITLE / ,
DATE I I d TIME I y LI P.M.
^ A.M.
THE NEXT SCHEDULED REINSPECTION 1 v P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the,public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has.the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five.or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410,550.
f 1 MR 41 00 not enumerated in 105 CMR 410.750 A through O shall be deemed to be a con
-
dition(P) Any other violation0 05 C 0 0 ( ) g ( )
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
Lf P,
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Parcel Detail Page 1 of 3
lite
KSTAUI y
Logged in As: Parcel Detail Tuesday, Octob,
Parcel Lookup
Parcellnfo
Developer;
Parcel ID 1251-056 Lot I LOT 54&5
Location 80 ANGUS WAY I Pri Frontage 205
......... . ....- ----- - -- -—-----
Sec Road ICENTER LANE Sec=150
Frontage
Village CENTERVILLE Fire District�C-O-MM
Sewer Acct Road Index�0031
w�.
rs x
Interactive
Map � ���
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Owner Info
owner STICKELLS, STEPHEN Nµ� co-owner
streets 67 CARLTON ST#3 I Street2
city jBROOKLINE - I StatePoMA zip a02 146 Country US
Land
Acres 0.68 Use'sSingle Fam MDL-01 ^I ., zoning RD1 ` -rughbd 0109
Topography ILevel m Road Paved
Utilities[Public Mate r,Gas,Septic Location
Construction Info -
Building 1 of 1
Year _ Roof -__.. _._.__ Ext
1958 Gable/Hi wall W Shingle
Built Struct p I ood
Effect , .m __ - _ Roof I" __. . . _.._._ ._ AC
Area i969 cover 1Asph/F GIs/Cmp Type:None
Style R wall Drywall Bed
anch Rooms' Bedrooms
Model Residential Int .__..__ __ _�HI Bath 12 Full + 1 H
Floor Rooms
..... _.._._..
Grade€Average TYPe:Hot.Water, Rooms 1 6 Rooms
http://issgl/intraneUpropdata/ParcelDetail.aspx?ID=18395 10/24/2006
Parcel Detail Page 2 of 3
stories 1 Story Neat Gas Found-cal
Fuel ation Yp
Permit History
Issue Date Purpose Permit# Amount Insp Date CoMIT
5/20/2004 New Roof 76778 $7,750 7/28/2004 12:00:00 AM
i- Visit History
Date Who Purpose
7/28/2004 12:00:00 AM Martin Flynn Drive by inspection only
10/2/2000 12:00:00 AM Paul Talbot Meas/Listed
--------
Sales History
Line Sale Date Owner Book/Page Sale P
1 STICKELLS, STEPHEN N 3383/161
I. Assessment History
Save# Year Building Value XF Value OB Value Land Value Total Parce
1 2006 $152,800 $2,500 $11,800 $258,200
2 2005 $138,800 $2,400 $12,100 $234,800
3 2004 $112,900 $2,400 $12,300 $273,900 ;
4 2003 $118,700 $2,400 $12,600 $50,400
5 2002 $118,700 $2,400 $12,600 $50,400
6 2001 $118,700 $2,400 $12,600 $50,400
7 2000 $84,900 $2,300 $13,100 $46,400
8 1999 $84,900 $2,300 $10,500 $46,400
9 1998 $84,900 $2,300 $10,500 $46,400
10 1997 $113,800 $0 $0 $33,700
11 1996 $113,800 $0 $0 $33,700
12 1995 $113,800 $0 $0 $33,700
13 1994 $107,800 $0 $0 $30,400
14 1993 $107,800 $0 $0 $30,400
15 1992 $122,900 $0 $0 $33,700
16 1991 $119,300 $0 $0 $59,000
http://issgl/Intranet/propdata/ParcelDetail.aspx?ID=18395 10/24/2006
r
Parcel Detail Page 3 of 3
� • .i
17 1990 $119,300 $0 $0 $59,000
18 1989 $119,300 $0 $0 $59,000
19 1988 $73,300 $0 $0 $33,200 ;
20 1987 $73,300 $0 $0 $33,200
21 1986 $73,300 $0 $0 $33,200
j� Photos
http://issgl/intranet/propdata/ParcelDetai1.aspx?ID=18395 10/24/2006
1, No. )00 —3 Fee
} THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pplitaction for Mi5po al *pgtem Con5truction permit
Application for a Permit to Construct( )Repair(1)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ® A,n S V-1 Owner's Name,Address and Tel.No. 8 j,_�71O—IW
Assessor's Map/Parcel
as/
6a
Installer's N�e,Addres$,and Tel.No,_ Designer's Name,Address and Tel.No.
i't e-- mcec_6l;r/Ir p
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder(O�
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design now tf I/C) gallons per day. Calculated daily flow gallons.
Plan Date Al-�,JO•- a003 Number of sheets Revision Date
Title
Size of Septic Tank � 'OCR GAL Type of S.A.S. .5-0069,l rAwlnarej a 3
Description of Soil 0 e-,20 2 _5Ano, �0/am D -�$ z.YAno4 /vgrn tgJi��ma/s -�/��_sae ►y�Ar,1
Y85— ��y — /�f�JT/»cf�<iivvl SAS ki. 4 Oy
Nature of Re airs or Alterations(Answer when applicable),Pwy(,c PXu I_4 f (�:).v oat fi 1eACV
;ciAa < A67.96Y t 3—SOO 8A CNAwtbaj C, A 311" x IQ, 3 c � l�fe`r�zavtc
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is ed by this Board o e th.
Si ned l/Date = 2 0200,
Application Approved b Date
Application Disapproved for the following reasons
Permit No. a00 Date Issued
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
" Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0(pplitation-for Migoal *p.5tem (Con.5truction Permit
t
Application for a Permit to Construct( )Repair(V )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ti u Owner's Name,Address and Tel.No.
Assessor's Map/Parcel C
A.
Installer's Name,Address,and Tel.
„(jrvice 14a_ce r/;Now Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size 30/ �0 sq. ft. Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �/z�U gallons per day. Calculated daily flow Z5 F . gallons.
Plan Date 126, . JO- 2003 Number of sheets Revision Date,
Title
Size of Septic Tank S OU GA0 Type of S.A.S. .5^00 6,3/ (fi;li�t�s'rk'J 3 /
Description of.Soil Q,+ �?0 r- 1 1.7 /Girl )1 �V`l" �u �A) �_, Gll�/, �J
i«
Nature of Repairs or Alterations(Answer when applicable) Pet %,�t -t /0_t�r,
5/7, •C % Lii /J%, 'Fa,�
a
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is ed by this Board oVHeath.
Si ned 'J Date 1,161; 45'--1
Application Approved b Date
Application Disapproved for the following reasons
Permit No. e -00 "�� 3 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
f
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired (6,�)Upgraded( )
Abandoned( )by ---tw; c c.;c •t�,l
at #� 4 i L r i�� `,�,�`"t c^4. 1�� has been constructed in accordance
with the provision ,of Title 5 and the for Disposal System Construction Permit No. 3'# 2 3 dated
Installer- 't.< �'lc,,C r j 1',l kk tt i,
Designer ..� l�,•��r 1-�}.UC
The issuance of his per4it shall not be construed as a guarantee that the system will t' s d s'
Date 'L 4/ Inspector
v
No. Pco Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
XigPo5a1 *p5tem Construction Permit
Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( )
System located at SO H
and as described in the above Application for Disposal System Construction Permit.The-applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Cons ction//must be completed within three years of the date of this 'yr ut.
Date: �C�/G' 3 Approved by�i�\ ��
TOWN OF ARNSTABLE
LOCATION 490 AAGUS WR y SEWAGE # 63-1's
VILLAGE Cer el l-u*,A ' ASSESSOR'S MAP&LOT ! --0
INSTALLER'S NAME.&PHONE NO. a-�'��(- --*—
SEPTIC TANK CAPACITY /5-00
LEACHING FACILITY: (type) 2b0 GAI CH, ,4, 10e"fJ (size) e3
NO.OF BEDROOMS r
BUILDER OR OWNER Ste P Sc�C�e�taS
PERMITDATE: .416-,.9_ORD09 COMPLIANCE DATE: Z
-Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
_Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
i
1 '
i
Pr
prc, 4 ,
�� - 35
y
COMMONWEALTH OF MASSACHUSETTS ' ,
EXECUTIVE OFFICE OF ENVIRONMENTAL RS '
DEPARTMENT OF ENVIRONMENTAL PR OTIONg- ,
ONE WINTER STREET, BOSTON MA 02108 (617) 292 "0 /i�0 d
Np
V 7 1998
WILLIAM F.WELD -�m/at• COXE
Governor r+uy ""rWF ecretary
ARGEO PAUL CELLUCCI D STRUHS
Lt. Governor otnmiScioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO
%� R. E
PART A
�®T — d)o CERTIFICATION
Property Address: 5 (� �`� �—r`� i �� z' L��.�� Address of Owner: 7SU50w"
Date of Inspection: Vo (If different) d
Name of Inspector: Mu •C-2
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: r � CYU K
Mailing Address: �i2-��L�,�i 4`-t;,€''
Telephone Number: ��•�"l, I�Z�
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:
Passes
_ Conditionally Passes
Needs Further Evaluation By t al Approving Authority
_ Fails c,
Inspector's Signatur Date: } L
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection.
If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the
appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any
failure criteria not evaluated are indicated below.
COMMENTS: r`n e z 5_K_1*-V-- o
4
V cl�' .ti S 1 u QTti t9x_
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.
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 04125/97) Page 1 of 10
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
� CERTIFICATION (continued) .
Property Address:e.'
Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
L'Sewage"bac up or,breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or
r
fl. due to a brok settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health).
Describe obse [tons:
'r1 - broken pipe(s) are replaced
obstruction is removed
tribution box is levelled or replaced
The system required pu ing more than four times a year due to broken or obstructed pipe(s). The system will pass inspection
if(with approval of the B rd of Health):
broken e(s) are replaced
obstructio is removed
CJ FURTHER EVALUATION IS REQUIRED BY BOARD OF HEALTH:
Conditions exist which require further evaluation 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 HEAL H DETERNMNES THAT THE SYSTEM IS NOT FLNCTIONTItiG INti A
N AN'N'ER WITCH «'ILL PROTECT THE PUBLIC ALTH AND SAFETY AND THE EN'VIROtiINtEN'T:
_ Cesspool or privy is within 50 feet of a surface wa er
Cesspool or privy is within 50 feet of a bordering v etated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH ND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERtiIINES THAT THE SYSTEM IS FUNCTIONLNG IN MANNER THAT PROTECTS THE PUBLIC HEALTH ANB
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SA and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the S is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the S is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SA is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria a d volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitr en and nitrate nitrogen is equal to or less than 5 ppm.
Method used to determine distance (approximation not v 'd).
3) OTHER
(revised 04125197) P2ge 2 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
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 MR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what wil be necessary to correct the
failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged AS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters du to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overlo ed or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume ' less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clo ed or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System. cesspool or privy is low the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a sur ce water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a ublic well.
Any portion of a cesspool or privy is within 50 feet o private water supply well.
Any portion of a cesspool or privy is less than 1 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well ha been analyzed to be acceptable. attach copy of well water analysis for
` ,coliform bacteria. volatile organic compounds mmonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the (lowing:
The following criteria apply to large,systems i addition to the criteria above:
The system serves a facility with a design ow of 10.000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment be ause one or more of the following conditions exist:
Yes No
the system is within 4 feet of a surface drinking water supply
the system is withi 200 feet of a tributary to a surface drinking water supply
the system is 1 aced in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone U of a public
water supply ell)
The owner or operator of an such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR .00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/2sr97) Page 3 or to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:' c�t lLiLf
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or 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 volumes 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 system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable)
[15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: .%/n , L7d
Owner: (tc • ,,(�
Date of Inspection:)
C FLOW CONDITIONS
RESIDENTIAL:
Design flow:4,�0 ¢.p.d./bedroom for S.A.S.
Number of bedrooms: O?�
Number of current residents:—AL>
Garbage grinder (yes or no): 0
Laundry connected to system (yes or no):
Seasonal use (yes or no):—I�—�
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):�
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_ allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readines, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL IN'FOR.MATION
PUMPING RECORDS and source of info cation:
info
System pumped as part of inspection: (yes or no) kY6
If yes, volume pumped: gallons
Reason for pumping:
TYP[K SYSTEM
I
� Septic tic t tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)_
(revised 04125/97) Page 5 of 10
rI
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
�}
Property Address:��Q �xl�k-�t
Owner: �4i lftir�Q
Date of Inspection.
BUILDING SEWER:
(Locate on site plan) VZ?
Depth below grade:
Material of construction: —cast iron —40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: S
(locate on site plan)
Depth below grade: OZ t
Material of construction: concrete metal Fiberglass —Polyethylene —other(explain)
M � — —
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: S V U
Sludge depth: 3"
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: II,
Distance from bottom of scum to bottom of outlet tee o baffle: ,i "1,•
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural inte ity,
evidence ofrleakage, etc.) V,)Cli WeE. 0 r �I
GREASE TRAP: tti�
(locate on site plan)
Depth below grade:
Material of construction: —concrete—metal —Fiberglass —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:
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.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 57& 6kl
Owner: ka ell��
Date of Inspec on: W I 0 4
TIGHT OR HOLDING TANK: ILlo (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons _
Design flow: gallons/day
Alarm level: Alarm in working order _ Yes: _ No
Date of previous pumping:
Comments:
(condition of inlet tee. condition of alarm and float switches. etc.)
►ISTRIBUTION BOX:jjj
(locate on site plan) —T
Depth of liquid level above outlet invert: '�f
Comments:
(note if level ana distribution is equal, evidence of solids rryover, evidence f leakage into or out of box, etc.)
�i•-�n'x G.u�� ��S.�lj�� t'�U►.J f- n,14_.vc Mr-,
PUA11P CHAMBER:,
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
�1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):--(.j
(locate on site plan, if possible.- excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_6-kk.
leaching chambers, number:_
leaching galleries, number:
leaching trenches. number,length:
leaching fields• number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(Zte condition of soil, sire of hydraulic failure, level of ponding, condition ege Lion, etc.) 1 �t
CESSPOOLS:.
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scu4n layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04125/97) Page s of io
TOWN OF ARNSTABLE
LOCATION 80 AVAGUS '(/J,�- SEWAGE # O6
VILLAGE Ce+el r� �l�'e , ASSESSOR'S MAP & LOT �1 "CJS
INSTALLER'S NAME.&PHONE NO.<-hO-P-C-((
SEPTIC TANK CAPACITY /100 G�*-1
a;LEACHING FACILITY:'(typ 'Joo GAL ctiArnuex— (size) 3
-3 �
NO.OF BEDROOMS J
BUILDER OR 00 E$ �t o P �C(�e�LS
PERMIT DATE:'-�/6-,2 9-aC OS COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge bf Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) _ Feet
Furnished by
-i - W,
A-.I
A-9rod Pr
Ac, 40
� ` g� � 33
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Cis+ L�
Owner:
Date of Inspec on: (u 1 t 1
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)
_ 1
Aw i
I
y �
I
C3- 39'� cc
Li 31
(revised 04/25/97) Pagc 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�r SYSTEM INFORMATION (continued)
� l
Property Address: (3 b�
Owner:
Date of Inspection:
i
Depth to Groundwater i 1�Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators. installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be comple
ted
)
>�a '���(\
(revised 04/2S/97) Page 10 of 10
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