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Home My WebLink About0025 CENTERVILLE AVENUE - Health 25 C;ENI'ERVILLE AVENUE A = 246-009 LOT 9 + 10 C.e i l r ilt Aso r r �i 1 II IIII �QECYCIEpco UPC 12543 No. 53LOR 57•C0NSJ� HASTINGS. MN aye - dog Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e`er ,M 25 Centerville Ave Property Address �"I Robbin Webber - Owner Owner's Name 'w information is `? required for every Centerville ✓ Ma 02632 11-13-15 page. City/Town State Zip Code Date of Inspection �a Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information (� filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. Excavation Company �a Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 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 ❑ Needs Further Evaluation by the Local Approving Authority OVI, " 11-13-15 Inspector's Signatu a Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 t5ins•3/13 P 9 P Y 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 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): Lt5ins 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 M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. A n h A is within a Zone 1 of a public water ❑ The system has a septic tank and SAS and the SAS 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 M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 page. CityTTown 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 31.0 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 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 laundryon a separate sewage system? Include laundry system inspection( rY Y P p g Y ❑ 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)): see below Detail 2013-27 000gallons 2014-24,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: May 2015 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 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: owner- last pump 2007 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ 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): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is Ma 02632 11-13-15 required for every Centerville page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' 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): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon 8" Sludge depth: 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 ,M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 page. City/Town 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 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" I Distance from bottom of scum to bottom of outlet tee or baffle 16" I! How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order with liquid level equal with outlet invert. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 page. Citylrown 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): 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 wM 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 4 page. Cityfrown 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 0" 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.): At time of inspection D-box is in working order with no sign of back up or carry over. 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gallon ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Chambers were dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information isequired for every Centerville Ma 02632 11-13-15 page., Cityrrown 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 Driveuat�' A Z NIN O 9 t5ins•3/13 / Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 15 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is Centerville Ma 02632 11-13-15 required for every � 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: No Gw 10' 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: Perk test on file with BOH dated 3-18-99 ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Perk on file with BOH 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 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 25 Centerville Ave Property Address Robbin Webber Owner Owner's Name information is required for every Centerville Ma 02632 11-13-15 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 i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 w ' No. "r Fee$10 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Digozar 6pgtem Construction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. 25 Centerville Ave . , O+nfrialdeso. w. Hyannisport Assessor's Map/Parcel112 Jefferson Ave . ,Everette , MA ��f" •�- 0staller' N A dress,and Tel. o. Designer's Name,Address and Tel.No. m. oinson peptic Service P 0 Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) install title-5 septic system Consisting of 1 , 500 gal.tank, D-box and , 2 leach chambers . 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 iss d by this and Health. Signed % k Dat Application Approved by Date r Application Disapproved for the following reasons ' Permit No. Date Issued :/ 19 r / 461 Fee $10 0 v .;.�J ,..THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes i rPUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSA H SETTS Apprtcatton for Mt-qpogal *patent Con.5truction Vermit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 25 Centerville. Ave .. , ory' JJMAddgUjpgT�o. W. Hyannisport 112 Jefferson Ave . ,Everette , MA Assessor's Map/Parcel / � . + Installer's,Narni�O b and son g e pt ie S eLry ie e Designer's Name,Address and Tel.No. Wm. E. P 0 Box 1089," Centerville , MA e Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ` Other Fixtures Design Flow 'dE. ,':gallons,per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title r` Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) install title-5, septic system Consisting of 1 , 500 gal.tank', D-box and ,2 leach chambers . y Date last inspected:t t 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 iss d by this and ealth. a Signed Date Application Approved by' Application Disapproved for the following reasons J Permit No. Date Issued Le' THE COMMONWEALTH OF MASSACHUSETTS Surette BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by Wm. E . Robinson Septic Service at 25 Centerville Ave . , W Hyannisport, MA has been constructed in acc c ord with the provisions of Title 5 and the for Disposal System Construction Permit No. � dated �A,y—Z 7 Installer Wm. E . Robinson S r. Designer The issuance o this permit shall no be of trued as a guarantee that the syste . ill function as designe„dg Date v Inspect<r G r No. !� THE COMMONWEALTH OF MASSACHUSETTS Surette PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ,. lwtopogaf *pgtem Conotructton Permit Permission is hereby ranted to Construct( )Repair(x ))U rade( )Abandon( )) Systemlocatedat 5 Centerville Ave . , W Hyannisport, M1� 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: Construction must b com leted within three years of the date of this t. Date: ��' / ;/ Approved b 1/6/99 r NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) . i I� William E . Robinson,SAereby certify that the application for disposal works C� construction permit signed by me dated 3✓ '" I , concerning the property located at �17 fr C4 A— �Ue meets all of the 4-,/- Wy1'4�va k� PoNr following criteria: • The-failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. I/The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. Lel There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] f e S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) / B) G.W.Elevation +the MAX.High G.W. Adjustment. = 1 DIFFERENCE BETWEEN A and B C,2 j(� Q SIGNED : DATE: 1(J 7 , [Sketch proposed plan of system on back]. q:health folder cert i•. -- '� .: � �;it � - � � �7 � 1 -------_, i 1 ,�a � d TOWN OF BARNSTABLE ?'9.�`� - LOCATION�^-(r. SEWAGE # VILLAGE-,P. CC-,V+ �� F ��' � A V(-- ASSESSOR S MAP& LOTZ��t�--VrO? INSTALLER'S NAME&PHONE N0. IJAI, -� dhi'�.ISoiJ SFAS,C 7? S-?77L SEPTIC TANK CAPACITY iSMO LEACHING FACILITY: (type) a (size) NO. OF BEDROOMS Z BUILDER OR OWNER PERMITDATE: 3I/ COMPLIANCE DATE: 2 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 leachingfacili ty) Feet. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feetChing facility) Feet Furnished by _%/t� l'I✓d > �IJ ,b" TOWN OF BARNSTABLE �9 /� LOCATION6"-- _ _ SEWAGE # ' VILLAGE a5 C'Fw'I'E2 v[ F ILL L ASSESSOR'S MAP& LOT��''��9 9 INSTALLER'S NAME&PHONE NO. GJN• &bt<,,190wJ S(VA 72 5-477/6 p SEPTIC TANK CAPACITY i SLD b LEACHING FACII.ITY: (type) .A 'DAV&*11i (size) NO. OF BEDROOMS Z ' Btff L-DER OR OWNER t9 uer PERMITDATE: 31&�J �-COMPLIANCE DATE: 2 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 QLlaaching facility) Feet Furnished by r GACk 0 kbvSC- . l r + 1 Ick • 1 i CERTIFIED MAIL#7003 1680 0004 5458 2452 Town of Barnstable Regulatory Services • BAMS A 4 • v MASS. �, Thomas F. Geiler,Director �AtFD Mp`I A,0 Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 co',c�wive 5 f�1v.� February18 2005 Ms. Lillian Surette 25 Centerville Ave. West Hyannisport, MA Via Certified Mail to Cape Winds Rest Home 349 Sea Street, Hyannis, MA EMERGENCY CONDEMNATION AND ORDER TO VACATE Finding of Unfitness for Human Habitation and Determination of Immediate Danger In accordance with M.G.L. c.111, sec. 127A and 12713, 105 CMR 400.000: State Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.000: State Sanitary Code, Chapter II: Minimum Standards of Fitness for Human, Donna Z. Miorandi, R.S., Health Inspector for the Town of Barnstable, on January 12, 2005 conducted an inspection of a dwelling located at 25 Centerville Avenue, West Hyannisport, Massachusetts. The property is owned by you, Lillian Surette. Based on the results of that inspection,the Barnstable Public Health Division has determined that the dwelling is unfit for human habitation. Pursuant to M.G.L. c. 127B and 105 CMR 410.831 (D),the Health Department further finds that the conditions within the dwelling are such that the danger to the life or health of the occupants of the subject dwelling is so immediate that no delay may be permitted in making this finding. Conditions found within the dwelling, which give rise to the emergency finding of unfitness and determination of immediate danger, include: 410. 750: Conditions Deemed to Endanger or Impair Health or Safety • Open food and garbage, along with rubbish observed strewn about in the unit. The above items were scattered on the counters,tables, furniture and the floors. • Stacks of dirty dishes observed scattered everywhere. I • Old meat and food containers and wrappings observed on top of stove. • Much dirt and feces smeared throughout the dwelling on floors and appliances. • Clothing and debris piled high on floors and furniture. CERTIFIED MAIL#7003 1680 0004 5458 2452 • Pots,pans, dishes observed strewn about on the floors. • Very filthy, unsanitary conditions observed inside the refrigerator. The occupant has caused objectionable odors inside her dwelling-emanating to the outside whenever a door is open. It is believed that this occupant may have a condition known as"hoarding" and may need social and psychological assistance. These violations of 410.750 (I) are also violation so of provisions 105 CMR 410.600, 410.601, or 410.602 as conditions which result in any accumulation of garbage,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. These violations shall be corrected within twenty-four y our(24)hours or prior to re-occupancy of P Y this dwelling by any person. 410.600: Storage of Garbage and Rubbish • Several bags of refuse observed on the ground behind the dwelling. j No refuse receptacles provided for the proper storage of refuse. The owner/occupant of any dwelling shall provide as many receptacles for the storage of garbage and rubbish as are sufficient to contain the accumulation before final collection and locate them so that no objectionable odors enter any dwelling. You are ordered to either(a) remove the bags of refuse from the property or(b) place the bags of refuse within rodent-proof containers (with tight fitting lids)within twenty- four hours of your receipt of this notice. Based upon these findings any and all occupants are hereby ordered to vacate and the landlord/owner is ordered to secure the subject dwelling within.48 hours of receipt of this order. If any person refuses to leave a dwelling or portion thereof, which was ordered vacated she may be forcibly removed by the local Board of Health (Massachusetts General Laws C. 127B), or by local police authorities at request of the Board of Health. Failure to comply with an order of the Board of Health may result in the issuance of a non- criminal ticket citation of$100.00. Each day's failure to comply with an order shall constitute a separate violation. Once vacated this unit may not be occupied without the written approval of the Board of Health. Note: This is an im ortantAecial document. It may affect your rights. Signed �, /YYJ egg,-, Cc: Ms. Lillian Surette , occupant and owner Thomas Kosman, Legal Services Mr. Tom Perry, Building Commissioner Robert Smith, Town Attorney Chief John Farrington, C-O-MM Department Thomas Geiler Ft ,ti Town of Barnstable Regulatory Services * snxivsrns�.e, v MSTA Thomas F. Geiler,Director �prEO MA'S ♦0 Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 30, 2006 Melissa Young Harborside HealthCare 161 Falmouth Road Mashpee, Ma 02649 Re: Lillian Surette Re-Occupany of dwelling located at 25 Centerville Avenue, Centerville Dear Ms. Young: I am writing this letter on behalf of your patient, Ms. Lillian Surette. Ms. Surette's house has been cleaned again for the second time by outside professional contractors. It is now in a habitable condition so that she can re-occupy the home. It is my personal recommendation that she not have a dog in her home. In addition, she will need assistance with personal care and activities of daily living. There needs to be a plan in place for rubbish removal. At present, her personal vehicle is loaded with debris and only room for a person to sit in the driver's seat. Driving a car in this condition is a hazard to the driver and others on the road. Si rely, a Donna Z. Mioran S. Town of Barnstable Health Inspector