HomeMy WebLinkAbout0031 BIRCHILL ROAD - Health PF 31 Birchill Road
Centerville
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Commonwealth of Massachusetts a6a0
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
31 Birchill Road '
Property Address
Estate of Sheila Burns �+
Owner Owner's Name t`'
information is Centerville MA 02632 11/12/16
required for every
page. City/Town State Zip Code Date of Inspection
W .
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 /0?o-�-�
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
use the return Name of Inspector
key.
tab
Ford Septic Services LLC
Company Name
P.O. Box 49
Company Address
Osterville MA 02655
City/Town State Zip Code
508-862-9400 S12482
Telephone Number License 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
SInspe
Needs Further a ation by the Local Approving Authority
11/15/16
s Signature Date
The s m inspector hall submit a copy of this inspection report to the Approving Authority(Board
of Hea 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
c
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is Centerville MA 02632 11/12/16
required for every
page. CityFrown 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:
® 1 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•3113 Title 5 Official 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
a 31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is Centerville MA 02632 11/12/16
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cost.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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 ❑ N ❑ 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 manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is Centerville MA 02632 11/12/16
required for every
State Zip Code Date of Inspection
page. Cityrrown
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 or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is MA 02632 11/12/16
required for every Centerville
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due 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 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
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 II of a public water supply well
If 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 failed. The owner or operator of any large
system considered a significant threat under Section E or failed 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.
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is Centerville MA 02632 11/12/16
required for every
page. City/Town 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?
® ❑ 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?
❑ ® . 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): n/a Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is required for every Centerville MA 02632 11/12/16
page. City/Town 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? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
unavailable
Sump pump? ❑ Yes ® No
Last date of occupancy: Date 6
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): 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:
!Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
u v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is required for every Centerville MA 02632 11/12/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: unknown
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
maintenance
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ 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 I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
U Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'w a 31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is required for every Centerville MA 02632 11/12/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
system installed -date unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: $
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ® other(explain)
cesspool block
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5'w x 5't x 6' btg
Sludge depth: 5
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9,•' 31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is required for every Centerville MA 02632 11/12/16
page. CityFrown 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 -
Scum thickness 4
Distance from top of scum to top of outlet tee or baffle 4
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? measure
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 cesspool is acting as a septic tank.The cover was 8" below. The liquid level was up to the outlet
tee.
Grease Trap (locate on site plan):
Depth below grade: n/a
feet
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:
Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is Centerville MA 02632 11/12/16
required for every
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 ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/a
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is required for every Centerville MA 02632 11/12/16
page. City/Town 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 n/a
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.):
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.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is required for every Centerville MA 02632 11/12/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number:
1
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The overflow cesspool was 5'w x 4't x 6' btg and had 2' of water on the bottom.There was no sign of
failure. The cover was 8" below.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration n/a
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
(Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
9�3W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is
required for every Centerville MA 02632 11/12/16
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.):
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.):
N/a
l5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
r
. • Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is
required for every Centerville MA 02632 11/12/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A � Q
A B
i aL a�
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
_ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
required for
is every
Centerville
required for eve MA 02632 11/12/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 25'+/-
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 property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Topo and water contours map.
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
see above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
31 Birchill Road
Property Address
Estate of Sheila Burns
Owner Owner's Name
information is required for every Centerville MA 02632 11/12/16
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
COMPLETE •N COMPLETE THIS SECTIONON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signatur
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse X / 0 Addressee
so that we can return the card-to you. B. Received bC.
■ Attach this card to the back of the mailpiece, y(Printed Name) 1 to of elivery
or on the front if space permits.
D. Is delivery address different from item 1 ftes
1. Article Addressed to: If YES,enter delivery address below: ❑No
Sheila Burns
36 Allan Rd. 3. Service Type
certified Mail ❑Express Mail
West Barnstable MA U2668 p Registered Retum Receipt for Merchandise j
❑Insured Mail 0 C. :6:
4. Restricted Delivery?(Extra Fee) Q yeS
2. Article Number 0 8` 3 i 2 3"�'`0 0 0 2'I S''17?i'8 9 3 3i i{
(transfer from service label) 0 w.'3�' ..
PS Form 3811 February 2004 Domestic Return Receipt 'f'+'
r ry ti Rt R it P �,��ry '4 ..�., 102595-02-M=1540
7—
UNITED STAis
.1'
W 9'ftt.%&aid
--.PeMItJ4O--G4
•
Sender: Please print your name, address, and ZIP+4 in this box
Town of'Barnstable
Health Division
R-T 200 Main Street
Hyannis,MA 02601
Date gWit 9
To Whom It May Concern:
I, Avemari*e- savzq ,voluntarily grant permission to the Town
(Occupants name)
of Barnstable Board of Health (Agent or Health Inspector) to inspect my dwelling unit
located at 3/ 81 rCh"i1 -20t �erU)%�,- 1*4 o�b 3 in accordance
(House#, [Apt\Unit#if applicable],street,village)
with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code
(105 CMR 410.000) on t/ItQ//o Q a,001 I hereby authorize and name
(Date of inspection)
rnanc* es In. b to be my tenant representative for the
(Occupant representative)purpose of this inspection. f'�'//''
4 CeS w ZQ is an adult person.
(Occupant representative)
designated and duly authorized to act on my behalf and will be accompanying the Town
of Barnstable Board of Health for the inspection, granting access to any and all locations
(including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and
answering questions. This authorization is only valid for the inspection date specified
above, and must be renewed for any future inspection(s.)
Occupants Signatur \ Date
Occupants Representative Signature \ Date
Q:\Rental Ordinance\inspection permission 2.doc
�bo
of'THE ram,
Town of Barnstable Barnstable
Y
ti
Regulatory Services Deppartment
k BAR BLE,
S a Y
yA . Public Health Division
�voo zb39, S��
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
January 20, 2010
CERTIFIED MAIL 7008 3230 0002 5177 8933
Sheila Burns
36 Allan Rd.
West Barnstable MA 02668
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY
CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
4 AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 31 Birch Hill Road, Centerville was inspected
on January 20, 2010 by Timothy B. O'Connell, R.S.;Health Inspector for the Town of
Barnstable. The 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 410.500: Owner's Responsibility to Maintain Structual Elements:.
Storm door on side of house not working as intended to. Door does not close properly
and has large gaps between storm door and prime door frame. T
You are directed to correct the violations listed above within thirty(30) days
of your receipt of this notice by repairing or replacing storm door so it works as
intended to.
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.
PER ORDER OF THE OARD OF HEALTH
Thomas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date ' J i) Time: In Out
n
Owneryv Tenant
Address -3 G Address r
Compliance Remarks or
Regulation# Yes O Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply
tulB.C� �f
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service -
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
17. Temporary Housing
18. Driveway Width
19. Number of Tenants Observed ) 5 0 � � �Z
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehicles Allowed (max)
Number of Persons Allowed (max)
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
FORM30 C&W HOBBS&WARREN'" THE COMMONWEALTH OF MASSACHUSETTS
' BOARD OF HEALTH
,F2 A/L/vS7 L
CITY/TOWN
o DEPARTMENT
000 MAI N 57 �4NN'S � OZGO
'c, SVByaW A DRESS oG` ��• Z /�� �yl
^'N CJJ
/� TELEPHONE
Address E3), 611"-H RIG/, /1./Jt �'ci,1"_,itu[. Occupant /�� mu i'% �0Z4
Floor — Apartment — No. of Occupants `Z
No.of Habitable Rooms No.Sleeping Rooms Z
No.dwelling or rooming units I No.Stories 1�-_
?���•Name
^and address of owner n _ LN
tfy�Q N'S Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual E ress: and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls: '
Foundation: \
Chimney:
BASEMENT Gen.Sanitation:
Dampness: 1.i.L, Hij�,-✓-3 \ o(3,L-
Stairs: N414 r) p
Li htin : fir, C,s� O 0 _ CLL
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
Bedroom 1 . \
Bedroom 2 (y
Bedroom 3
Bedroom 4
Hot Water Facil. Su .,Gas,Oil, Ele
tacks, Flues,Vents,S fe*s:
Kitchen Facilities Sink
Stove
Bathing,Toilet Fac .
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other: V\ P.� 0 �N-C j d
Egress Dual and Obst'n: 1:— Ir,,S3� k^ .-
General Building Posted �qo 7/5�r
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 INSPECT ON REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF ERJURY." �p p,t� CAG&-[
INSPECTOR TITLE �N
-o
A.M.
DATE A TIME-
7
2 A.M.
THE NEXT SCHEDULED REINSPECTION 1��' P.M.
-♦ •- vi • Fin _ r:V . �•�ry[ , • r - r
r
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 well-being of the
occupants or the public. Because Chapter 11, 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
1 MR 410.200(B) nd 410.202.
rohibited b 05 Ca
p Y
(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.
(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.
Postal
CERTIFIEDMAILT. RECEIPT
r� i. Only,
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7207�F:I�Cl �A L U S E
l�
Q'
��y Postage $
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Certified Fee �G & ",
p ostmatk
Return Receipt Fee \
C3 (Endorsement Required) (� Here
Restricted Delivery Fee
[p (Endorsement Required) `b
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cc Total Postage&Fees $ ! �Q9Zfj
Sent To N�1`A �U DNS
O Street,Apt.No.;�� �L, w
P- or PO Box No. W
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Certified Mail Provides: r
■ A mailing receipt `
■ A unique identifier for your mailpiece
■ A record of delivery kept by the Postal Service for`two years 5
Important Reminders:
■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return,
Receipt(PS Form 3811)to the article and add applicable postage to cover the,
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPSC postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
i COJMPLETE THIS SECTION SENDER: COMPLETE THIS SECTION
ON DELIVERY
■ Complete items 1,2,and 3.Also complete A.;M4
item 4 if ii-estricted Delivery is desired. X ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. . �eive (Pri d Name) C. Date f De ivery
■ Attach this card to the back of the mailpiece, vliVt S t (S G
or on the front if space permits.
D. Is delivery address different from item 17 ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
i
3G AL-LA,a fib.
t-�-1— 3. Service Type
jkCertified Mail ❑Express Mail
❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4_ Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number f I t; i { s7 8 1'83OI 0002'�Q.49.9
ffimsfer frcim service label) `
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PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED STATES
"Pow vwja.-..�
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. ...........
Sender: Please print your name, address, and ZIP+C--Ointhis box •
Town of Barnstable 6 :k
Health Division
cv
200 Main Street
Hyannis, MA 02601
°F tr+e r°o
Town of Barnstable Barnstable
Al-A� Services Department `�eaC�Regulatory S p I
,i 6ARNS1'A6LE, ` �
Public Health Division
��O i639 `gym
ATFD MA1 a, 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
November 17, 2008
CERTIFIED MAIL 7008 1830 0002 7114
Sheila Burns
36 Allan Rd.
West Barnstable MA 02668
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 31 Birch Hill Road, Centerville was inspected
on October 23, 2008 by Jaime Cabot, Health Inspector for the Town of Barnstable. The
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. vV j 2'7 "I �'�
105CMR 410.480 (A): Dwelling Unit is Secured Against Unlawful Entry: ICI
Bulkhead door frame is damaged, the interior door frame has been broken and the door to
the cellar falls off when opened.
105CMR 410.550(A): Extermination of Insects Skunks and Rodents:
Evidence of rodent activity was observed in the basement.
You are directed to correct the violations listed above within thirty (30) days
of your receipt of this notice by repairing the bulkhead door and the door in the
basement that leads to the bulkhead.Monitoring the dwelling for rodent activity is
recommended.
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.
PER ORDER THE BOARD OF HEALTH
o ?as A. cKean,R.S., CHO
Director of Public Health
Town of Barnstable