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HomeMy WebLinkAbout1228 CRAIGVILLE BEACH ROAD - Health 1228 Ci a-igville Beach Rd iCenterville P A = 206 109 t , t . f � a NO. 152 1/3 ORA I .'. _ „'ter--'. 3 9,0 r I A� v O T 1 � 5s 5� 3 �I � rIA wvl-, �S v J i r r Certified Mail#7012 1010 0000 2850 7862 �t T Town of Barnstable o� Regulatory Services BAMSCABM s v� XAS& Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 4, 2013 Daniel Dipierro 40 Franklin Avenue Hyannis, 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 1228 Craigville Beach Road, Centerville, MA was inspected on April 3, 2013 by Timothy O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint received by the Town of Barnstable. The following violations of the State Sanitary Code were observed: 105 CMR 410.351 —Owner's Installation and Maintenance Responsibilities A leak was observed coming from drain pipes located within the basement of said dwelling. 105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements Closet within the second floor bedroom had signs of chronic dampness. (Wet insulation and mold like substance) The following violation(s) of the Town of Barnstable Code were observed: 1� 70-4- Certificate of Registration—Rental property is not registered with Barnstable Health Department for 2013. You are directed to correct the violations listed above within fourteen (14) days of your receipt of this notice by repairing leaking pipe(s) ; by stopping source of chronic dampness within second floor bedroom; by registering rental with Health Division for 2013. Q:\Order letters\Housing violations\1228 craigville beach rd. 4-4-13 i You may request a hearing before the Board of Health if written g petition requesting same p q 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. S DER OF T BOARD OF HEALTH 1. A. McKean, R.S., CHO Director of Public Health Town of Barnstable Q:\Order letters\Housing violations\1228 craigville beach rd. 4-4-13 y Citizen Web Request Page 1 of 3 z�y� 7�111 BARN l f3 A } NIASS Ar a Logged In Citizen Request Management 1 ent Thursday,April 4 2013 TOWN\oconnnnelt Route to Users Search Requests Create Requests Request Information Request ID: 44795 Created: 4/3/2013 8:22:50 AM Status: Assigned To Staff Assigned To: O'Connell,Timothy Health Office Anonymous: No Request Category: Chapter II : Housing Substandard edit Routine work: No Estimate: No edit Date scheduled: edit Estimated 4/18/2013 Change Estimated Mar April 2013 May Completion Completion Date: Date: Sun Mon Tue Wed Thu Fri Sat 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 1 8 12 110L11 Created By: O'Connell,Timothy Priority: Medium edit Health Office Citation Numbers: edit Requestor Information Requestor Request Parcel Number Ma 0000 p' 0 —1 Block: Fggo--Lot: 000 Housing violations Parcel Lookup Email: Edit Requestor Information http://issgl2/intemalwrs/WRequest.aspx?ID=44795 4/4/2013 Health Master Detail Page 1 of 1 Logged In As: TOWN\oconnelt Health Master Detail Thursday,April 4 2013 Application Center Parcel Lookup Selection Items Parcel Septic Perc Well Fuel Tank Parcel: 206-109 Location: 1228 CRAIGVILLE BEACH ROAD, CENTERVILLE Owner: DIPIERRO, DANIEL I Business name: _ Business phone: Rental property: r Deed restricted: ❑ Number of bedrooms : 0 Contaminant released: r Fuel storage tank permit: r Save Parcel Changes Return to Lookup v re, __�. m . Parcel Info Parcel ID: 206-109 Developer lot:LOTS 1 &A Location: 1228 CRAIGVILLE BEACH ROAD Primary frontage:50 Secondary road: Secondary frontage: Village:CENTERVILLE Fire district:C-O-MM Town sewer exists at this address:No Road index:0369 Interactive map: ' T AP (Aquifer Protection Overlay Town zone of contribution:District) State zone of contribution:OUT Owner Info Owner: DIPIERRO, DANIEL Co-owner: Street1:40 FRANKLIN AVENUE Street2: City:HYANNIS State:MA Zip: 02601 Country: Deed date: 10/11/2012 Deed reference:26751/308 Land Info Acres: 0.45 Use: Multi Hses MDL-01 Zoning:CBDCRNB Neighborhood: 0108 Topography:Level Road:Paved Utilities:Public Water,Gas,Septic Location: Construction Info Building No ear Built Gross Area Living Area Bedrooms Bathrooms 1 1900 3497 2198 7 Bedrooms2 Full 2 1910 926 926 2 Bedroomsl Full Buildings value:$222,000,00 Extra features: $40,900.00 Land value: $201,000.00 http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=206109 4/4/2013 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address C�rnc s, Dytso-5!��D.fox D, �/o,�ro.�r,•�l. s, oz��� Owner Owner's Name information is r required for � '�/5 JIUr!r• Z every page. City/Town State Zip Code Date of Inspection. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information I forms on the tttTTT �/1 computer, use 1. Inspector: only the tab key to move your cursor-do not use the return Name of Inspector key. 7D A/y `IDt�D/S�/�il�D s /N.lri4rl0�✓,�f.66�11f Company Name Company Address City/Town State Zip Code 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 Inspector's Signature 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. t5ins•11110 Title 5 Official Inspection or :Subsurface Sewage Disposal System•Page 1 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address eyrs D A.1 Owner Owner's Name ?�2.3/�Z information is /7iV$5• required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: hl,# ❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments M 'g.2 �rZI�U1LGfy,�c� Property Address —' C/��us ���s o•� Owner Owne_ is Name information is / NAIIs of required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution;box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ 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-11/10 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 Property Address Owner Owner's Name information is required for f� every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El due 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 ❑ ❑ yp than '/Z day flow t5ins-11/10 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 J�22 yILL f e4f!CO /Icy Property Address Owner Owner's Name information is //y�,�,�,,,5 AAss. CJ260/ 7/7 required for 3 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Q 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. ❑ ❑11Yh Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑�/f} Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑/S/`}- Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ My 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official InSpection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Property Address Owner Owner's Name information is //y���`S �/ 'S, d,2�f 2XZ2 �Z 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 [X ❑ 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) '101451; D AJJ S [ ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? [�J ❑ 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-11/10 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 M /ZZ£r L�/Z•�slGylLGf l3f�G� ,� Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: /yid Number of current residents: G Does residence have a garbage grinder? ❑ Yes 5� No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes [ No Laundry system inspected? ❑ Yes ❑ No&A Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: /YD OCG4alpfo 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every 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: �Nhf Z 02 �IZ��O/LrJS 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: 4 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address - Owner Owner's Name information is /y��y�5 �¢ss� 62��j� 7/ z//Z required for �7 �/ every 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: /S IAS zU V /07 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan):Depth below grade: `l ' 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: To G�aI 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: S' 6'x/9' Joao Gc-' Sludge depth: t5ins 11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /,2-Zk elzole,('111-L f NIsel-I - Property Address P Y C «des �.v�sow Owner Owner's Name information is y.�i�✓.�1..5. 4.2 6 01 712Z//Z required for every 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 d.G " Scum thickness Distance from top of scum to top of outlet tee or baffle All ' Distance from bottom of scum to bottom of outlet tee or baffle Nf,415,Vle/A✓6 5W CI' How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity; liquid levels as related to outlet invert, evidence of leakage, etc.): /If'CC oa4 f.y n Tif.va iclE�a.rvp� oSoa.✓ /N f oar7"s Ga o 0 .�Y/1'6/CTUJZ�[. /�►7.Go c o, i' NoyE Grease Trap (locate on site plan): De pth 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. t5ins•11/10 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 12W - Property Address - ef!�/Z/S Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) �d Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Nb�yF 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts u. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is lT�/�i��,/LS �►� •, 0Z`D/ 71z3I1 z required for / 3f every 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 0"Y11 fy APH-h D�tTL+<7->A/v fx7 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.): ,( fvf,L , 0-1:5 r rO Oa7X-0rFc�! ,Go �vi-0 a4- Sa�i�s C19 /t/avF,t dle -uioF.vc¢ aVe, « f r Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes 0 No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ln1�IZiS �l�L,Sps/ Owner Owner's Name information is �fj/p�,y�s• AAWC • O.2 Ld/ 7/Z Z�/Z required for every 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: 3$'X 3.5- ❑ 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.): �i ,, i 1 1• 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address L's�iz<s ��L So w Owner Owner's Name information is �/� required for every page. City[Town State Zip Code Date of Inspection D.. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding,.condition of vegetation, etc.): �d pf 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•11/10 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspecti®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every 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 G213lGu�r-C-C �fl�-C.�- �L�✓ xk �u�s� I�ousf �1- li — t5ins•11/10 Title 5 Official Inspection Porn:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form' _ o Subsurface Sewage Disposal System Form Not for Voluntary Assessments M A:22 �/Zf�/L U/LLF ✓��/�Cd� /1�� Property Address elywS Owner Owner's Name information is ,// d-.� 712 required for /� 1WNy45- ? every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: © Check Slope ?'a Surface water ,Z/P100' 0 Check cellar © Shallow wells /�0/'74' Estimated depth to high ground water: feet Please indicate all methods.used to determine the high groundwater 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: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: C7 0r1l fo ?JeSiaN Before.filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F®rr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12.2k G�iz. Zvi F �3r�c�u 0& Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist [2 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 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Your Septic Sysiem and Ho It is important to understand how your system works and how this treatment affects it in order to protect your investment. The typical system consists of three (3) main components. ® The Septic Tank The Distribution Box The Drainfield The Septic Tank. Waste exits the house and enters the septic tank where solids settle to the bottom, grease and scum from the household detergents float to the top, and liquids stay in between. The solids that settle create their own bacte- ria which decompose the solids naturally. There is no need to add additional enzymes and bacteria to the tank. The tank eventually fills with solids and scum requiring it to be pumped. A septic should be pumped every two (2) years. The DrainfieId The liquid (gray water) flows to the distribution box where it is evenly dispersed into the drainfield. Finally, the drainfield begins treating the gray water. Microorganisms in the soil consume organic pollutants in the gray water and the pure water is absorbed by the ground below. How Problems Start From the first day of use, the drainfield of your septic system begins to deteriorate. Some solids, grease, and scum always pass through the septic tank into the laterals. This is because of natural solu- bility or the lack of setting time in the septic tank during periods of heavy use. Problems especially arise when the septic system is not maintained and the septic tank fills with solids and scum that overflow into the drainfield. As the drainfield becomes clogged, the water flow becomes restricted. Since the water cannot drain into the soil, it filters upward causing ponding, foul odors, wet spots in the yard, and an unhealthy envi- What Causes Problems What you don't read about is that bacteria has a waste called biomat, and they also create a gas, bacteria eats human waste. It does not eat,hair, wool, polyester and other particles. The biomat is like grease. The gas cre- ates bubbles and. this causes particles to float up the T and into the distribution box and into the leeching fa- cility, plugging up the stone. Septic tanks should be pumped every two (2) years. Cesspool Cesspools were made by digging a hole in the ground and walls were made of stone then later on they were built with concrete blocks. The waste entered the cesspool, and solids settled to the bottom, the liquids seeped out the sides into the soil. Cesspools should be pumped every year. State Environmental Code Title V Chap. 5 Inspection Procedures Guidance on Completing Inspection Form Part A Certification. The Certification Section has two principal functions. First it provides identification information on the property being inspected and the inspector. Second, it presents the results of the inspection relative to the failure criteria outlined in 310 CMR 15:303. In the certification statement, the inspector is certifying that the conditions existing at the time of inspection are accurately presented in the inspection report. The inspector is not certifying that the system is adequate for the current use of the system nor for the future use of the system. TONY CAPONIGRO 216 North Main Street Mansfield, MA 02048 Title V Inspections 1 ' Certified Mail#70062150000210387336 Town of Barnstable Regulatory Services + BARNSFABLE, v� 6 9 `0g Thomas F. Geiler,Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July, 29, 2008 Brigita Petrutis 1228 Craigville Beach Road Unit B-2 Centerville, MA 02632 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 '1228 Craigville Beach Road, Unit B2 was inspected on 07/18/2008 by Jaime Cabot;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 wer observeDd 105 CMR 410.503(B)—Protective Railing and WallRailing on stairway shall have balusters or ornamental c sures w passage of an object five inches or more in diameter You are directed to correct the violations listed above within 30 days of your receipt of this notice by repairing railing on stairway. 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 BOARD OF HEALTH Thomas A. McKean, R.S., CHO QAOrder Ietters\Housing violations\Rental ordinanceWddress.doc l �_ yJ f You are directed to correct the violations listed above within 30 days of your receipt of this notice by: adjusting water temperature so that it is reaches between 110-F and 130o F 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 $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection.. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO QAOrder letters\Housing violationARental ordinance\Address.doc FORM30 C&w HOBBS&WARREN in THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN W H f—A 04 DEPARTMENT 2 00 tylA\ �t ST. �A t M A, o Z(oa 1 ADDRESS V (S'0 S) 8/ Z- L//(O y9/ M sey`0 C'J TELEPHONE � G�/vtsl�.Vllr�.f, Address 2 Z 8 C 12Q i 4q\/I LLI UAU4 Occupant . 'raw o,a A S G a d!A rAA- Floor Z Apartment No. 9 'L No.of Occupants of Ao O Sr Aft C"cw.- 40U_4,%-�, No. of Habitable Rooms *1 No.Sleeping Rooms 2 Cq HA't I- No.dwelling or rooming units_. No.Stories 'L-- Name and address of owner Sg 1 TA t s . ,� 2 Z 5 (a C. 1L 1FA eg$JTI*aV J ILLf_ -AA- Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: IA)9- WA 9AILIPIC4 NOT Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: 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 Vents lww se IL To Q L QnI ELECTRICAL Panels, Meters,Cir.: ,o ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wirin : DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom(1), (5 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: 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 Ie H 1 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 INSPEC N REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES ERJUR " INSPECTOR TITLE 17f'Q67q ZN 702 A.M. DATE TIME /,'Q0 P.M. A.M. THE NEXT SCHEDULED REINSPECTION 784 P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found.to.exist.in residential premises,shali 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 1.1, 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 CMRA10.830 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. (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 upcn the failure of the owner..., _ M to remedy said condition within the time so ordered by the Board of Health. �� Certified Mail#7006 0810 0000 3524 8936 �0.*1HE ra Town of Barnstable ° Regulatory Services BARNWABLE, ' y. MASS. Thomas F. Geiler,Director �p 039. 1m °►�AYa, Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 22, 2007 Brigita Petrutis 1228 Craigville Beach Road Centerville, MA 02632 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 at1228 Craigville Beach Road B 1, was inspected on March 16, 2007 by Meredith Morgan, 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 410.351 —Owner's Installation and Maintenance Responsibilities. Light fixtures in bathroom missing covers. 105 CMR 410.500 —Owner's Responsibility to Maintain Structural Elements. Peeling paint in bathroom. The following violations of the Town of Barnstable Code were observed: 170-10— Smoke Detectors and Carbon Monoxide Alarms. No CO detector within home. QAOrder letters\Housing violations\Rental ordinance\1228 Craigville Beach Road BLdoc You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice installing CO alarm. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by fixing peeling paint and by providing light covers for fixtures in bathroom. Note: COMM has been notified that there were no CO detectors within home at the time of inspection. 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 T BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Meredith Morgan, Health Inspector QAOrder letters\Housing violations\Rental ordinance\1228 Craigville Beach Road B1.doc You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice installing CO alarm and by repairing or installing operable smoke detector. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by replacing ceiling tiles and by providing covers for light fixtures throughout home. *Note: COMM has been notified that there was an inoperable smoke detector and no CO detector within home at the time of inspection. 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. io�m�as R ORDER OF HE BOARD OF HEALTH A. McKean, R.S., C1 Director of Public Health Town of Barnstable Cc: Merdith Morgan, Health Inspector QAOrder letterMousing violations\Rental ordinance\1228 Craigville Beach Road B2.doc l l --7 9.3 COMMONWEALTH OF NLASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTE.CTI_QI 11ii nn JA TOWN OF BARtiSTABLE HEAL 1 H DEBT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ' e{e,�p MAP --- PARCEL �— Owner's Name: LOT Owner's Address: C7 Date of Inspection: Name of Inspector: lease print) 14-1, Company Name: Mailing Address: Telephone Number: .. 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 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 Needs Further Evaluation by the"Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of`Healih 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 p DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. " Notes and Comments ****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 Inspection Form. 6/15/2-000 page 1 Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address: C Owner: _ Date of Inspection: Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: " I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: & 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of II OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART-A CERTIFICATION(continued) Property dress: C9 Owner Date of Inspection: (� C. Further Evalu on is Require 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 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 -A . .* This systemgasses if.the;well.water analysis,performed at a DER certified lzboratory,V�r:eoliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3 Paoe 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property ddress: y � C Owner. Date of Inspection C/ P T— D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Nc� _ / Backup of sewage into facility or system comporent 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 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped V-� 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 j water supply. _ U Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. V 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 coliform bacteria and volatile organic compounds' indicates that the well is free from pollution from that facility 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.] (Yes/No)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- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Pa-e 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CI1ECIaIST Property Address: Owner: Date of Inspection. Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes -No _t✓ Pumping.inform ation.was provided by the owner, occupant,or Board of Health LZ Were,any of the system components pumped out in the previous two weeks? GZ_ Has the system received normal flows in the previous two week period? qZ/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 off the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? t/ _ 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: Yes no Z— 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: Owner , Date of.Inspection: LOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actuaI): DESIGN flow o based on 310 CIviR 15.203 0 for exam ple:mple: 1 l0 bpd x#of bedrooms):.- Number of current residents:� Does residence have a garbage grinder(yes or n ): Is laundry on a separate sewage system ( �es or no): [if yes separate inspection required] Laundry system inspected( es or rl�1�W Seasonal use: (yes or no): Water meter readings; available(last 2 years usage (gpd)):OZ ' Sump pump(yes or no : Last date of occupan y: , COMMERCIAL/INDUSTRIAL,41�— Type of establishment: Design flow(based on 310 CM11.15.203): gpd Basis of design flow('seats/persons/sgft,etc,): 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 readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records 101,1 Source of information: Was system pumped as part of the insp ction{yes or nR :,4 If yes, volume pumped: gallons--How was qua rty pumped determined? Reason'for pumping: ; TYPF OF SYSTEM , eptic 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) _Tight tank _Attach a copy'of the DEP.approval Other(describe): proximate a e o all co..pon nts,date ' stalled know ) d so rce of information:. Were sewage odors detected when arriving at the site(yes or no 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued) Property Address: Owner: Date of Inspection. BUILDING SEWER(locate on site plan)'� Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain":' i Distance from private water supply well or suction line: I - Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK:_V (locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ is age confirmed by a.Certificate of Compliance(yes or no):_(attach a copy of certificate) _ Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 6 �t Distance from top of scum to top of outlet tee or baffle: L Distance from bottom of scum to bottom 9f outlet tee or baffle: How were dimensions determined: Comments(on pumping recommen ations nlet and outlet tee or baffle condition, structural integrity, liquid levels s related to outlet invert, evi ence of leakage, c.): t Ac �.�C7 ri GREASE TRAP `,�Oocate 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(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATIO (continued) Property ddress: 0';)' � Owner: Date of Inspection: TIGHT or HOLDING TANK-/d4'�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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: Z(ifent must be opened)(locate on site plan) Depth of liquid level above outlet.invert{ � r ��qual,Comments(note if box is level and distributiontoounce of solids carryover, any evidence of akne into or out of bo c6,.): J':� 4 PUMP 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, 66c:): 8 L Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A Owner: PA Date of Inspection: SOIL ABSORPTI 'SYSTEM (SAS): ocate on site plan, excavation not required) If SAS not located explain why: Type leaching pits;number:_ leaching chambers, number: leaching galleries, number: ching trenches,number, length: r/ leaching fields, number; dimensions: z,Z)- x o 6 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. C. CESSPOOL(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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY:-40—(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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOICq PART C SYSTEM INFORMATION(continued) Property -(.Jdress: ,Z) w Owner: Date of I spection: SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks orbenchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. coo U 10 10 G Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property A ress: � ' C Owner: Date of Inspection: 40 0 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to around water feet Please indicate(check)all methods used to determine the high around water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) ✓Accessed USGS database-explain: You must describe how you established the high ground water elevation: � nel- 20 Wr ,S 11 Permit Number: Completed bV: 5Ay HIGH GROUND-WATER LEVEL COMPUTATION Siie Location: � Uf • -� Lot No. " Owner: - Address: Contractor:_ :•.'O ^C©d�� Address: J� y Notes: . STEP Measure depth, to Water table . to nearest ?/10 it. ................... g°`� --_--! ......... ... .Date month/day/year STEP 2 Using Water-Level R-ange Zone and.1ndex Wel'I'Map locate i site and de-:ermine: �,'/. ,4ppro.priate index well........ Gf/ .......... 1/.......... Waterdevel range zone ....-. p 3 Using monthly report "Current j Water Resources Conditions" determine current depth to water level•.or index vvell .-.... month/year C T `O q Using •Table of Water-level Adjustments 1 " I .or index well (STEP 2 A), current depth to water level for index.wel; (STEP 3)., i 'and water-levei'.zone (ST� 2B) determine water-level adiu'stment-....... l ..........................................................................-....... Estimate depth to high water by subtracting the water- level adjustment (STEP 4) rom:"measu red'de'p,h to water level at site (STEP ? " " .................................. I �� ' Figure 11--Repr0dUcible co-lpj�r-on,io;in. f , J9 1 F { . E Z - i ti si (�p i r 1 } ! t G i N n -1 tj - r r C a�F i ! G i 1 � 1a S �1 n N u' _ 4 4• S No. �y-Z'j�j7 -z-7 Fee' - � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pprication for )Die;pogar *pgtem Cott5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 72-g' Grp �/Ile. wner's Na e,Address and T 1.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. '7 7/--� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building e✓/ e- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow F49 gallons per day. Calculated daily flow 5 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7 fle V 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 issued b this and Healrt� - ` Signed Date Application Approved b r Date '�� � Application Disapproved for the following reasons Permit No. '°" Date Issued " No. Vw- 5•s "° Fee T GfP� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes _ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01ppricatiou for M gpogar *pgtem Congtruction Vermit 4 Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Z "10 Ili d 4 V 4,,Pwner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �l Designer's Name,Address and Tel.No. �o�taGa�f Gor�77 Type of Building:Dwelling No.of Bedrooms 73 Lot Size sq. ft. Garbage Grinder(1110 Other t Type of Building G5% P/1GG No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow *8�/ gallons per day. Calculated daily flow 1r gallons. t Plan Date Number of sheets Revision Date Title- - Size of Septic Tank ZO©09G�� Type of S.A.S. Description of Soil . Nature of Repairs or Alterations(Answer when applicable) 7/17`/to 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 issued by this B and o Hea Signed Date Application Approved b AL4~ Date Application Disapproved for the following reasons Permit No. Date Issued --- --------- ---------!----------- ,--- /— —y--- THE COMMONWEALTH OF MASSACHUSETTS �: ✓�� / BARNSTABLE, MASSACHUSETTS (fertfftcate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( ' )Upgraded(l� Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction_Permit NV:Z "� dated Installer Ale! ��: l_ ,f% � [j s�`; Designer � _ The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date :Z -- In "l Inspector t No. ——�--------------------�0� /L/ / Fee �1:1,Ir-W THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migogal *pgtem Comaruc ton i3erntit Permission is hereby granted to Construct( )Rpm ( )Upgrade Abandon( ) System located at /Z 2 G n''A;Zj. e� z //e 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 be completed within three years of the date of this Tmit. Date: / Approved 6 ,f NOTICE: This Form Is T® Be Used For the repair Of Failed Septic Systems Only. CERTIFICATION DE SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, hereby certify that the application for dis posal works construction Permit signed by me dated .S �11?7 concerning the property ylocated at /Z Zo meets all of the following criteria: T re are no wetlands within 300 feet of the proposed septic system re are no private wells within 150 feet of the proposed septic system /'/nee observed groundwater table is 14 feet or greater below the bottom of the leaching aciiity 1 ere is no increase in flow and/or change in use proposed There are no variances requested or needed. SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert -- n n� 1 5S S� v � 3 �I i <ob_ /o 7 �y9 _. LOCATION SEWAGE PERMIT NO. /.z z p, VILLA/G� E ALL LLER'S NAME i ADDRESS C94-ts" OR OWN E I/ V/Ai�/ h DATE PERMIT ISSUED -_�� _� � DAT E COMPLIANCE ISSUED II �I TOWN OF BZrl T2SEWAGE 4L ATION ��Z (� %g�/�`L� # VILLAGE G�l'I �/��� ASSESSOR'S MAP & LOT WV I©f INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Fa C d (size) 3 g'X 3.7 A ,v NO.OF BEDROOMS / BUILDER OR� PERMIT DATE: S—/ `" COMPLIANCE DATE: 2 / Separation Distance Between the: 7 Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) --G Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r 8' }�JJ 6 yib� sib` Sob' 00 _ _ No&QmA�... ,: FE:B $.... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..................Town.............OF...............Barnstable----------------------------.................... Appliratinn for Dhipoii al Workii Tnnitrnrtinn Permit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 1228 Cra Z idle.. ct�.R�,..,_.Qen er5ti17 a..D26 2----....-•----. ............. -28.• a Location_Address or Lot No. Mrs. Russell 111i.t.Q&........................................................ Beaah.,Ri.-,...Center-4l1e-42632 Owner Address a A &_.$..Q �o01_.SA Y .ae.................................................. 12a..Bishops.Tnxraaar--Hyarmis-,.--MA-----02b01... Installer Address Q Type of Building Size Lot............................Sq. feet U g— ..._,,..._Expansion Attic ( ) Garbage Grinder ( ) �., Dwelling No. of Bedrooms______________________�______.. • -� _-_.-______- Showers — Cafeteria Other—Type of Building ____________________________ No. of persons_..._._.._.__ ( ) ( ) a Other fixtures ----------------------•------_--_ _ i W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by--------------------------------------------------------------------------- Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (� Test Pit No. 2_ �......._ iinZtesihI.- 0epth o ,Test Pit________ __________ epth rou ater---------- Descri Description of Soil....._... Sam _ I' _ -� __ ------ x _ - W -----•---•-•-•----. . pst.- ! wc.-.�� -�--------------------•-••---•----••--------------•-- UNature of Repairs or Alterations—Answer when applicable...i.nstallation--Q.f-,a-.flowdifuss=s4---------------- stone..packed.. ---------------------------•------------------------•------------------------------------------------•-----••................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of :7:L. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board;o�if�..hh- lth. S' .ned.. .r!C_cffrt'= .i=•.; :2n� ._-•---- 5 $ 0..... - n'pp ate GA $[ Application Approved By.__--_ __ .__— . _ � .........5/ _ Date Application Disapproved for the following reasons:........ ---------------•-•------------------------.......................................................... ----------------------------•--•----------------------------------------------•-.._..........-----------------•----------_------------------------------------------------------••---------•------------ Date Permit No.. ...0-.............. Issued_ 5 -28 .80...........•-••--•--- Date 3 RmB THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ :------:-----OF...............a, Appfiration for-UWpoBai Workii Tnnitrnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal System at 12,2a-• 1�^�ti f3- I ##pp• .3 ct E;?' 2 -------•........................•----•-_.................................................... .�ocatrom-Addcess or Lot No. ------ ------------•-----................_-- y Owner '� ess 3 Installer ddres Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms______________________�............_-------Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons---_......_3______________ Showers — Cafeteria dOther fixtures -------=----------------------------------------------.-.--------------------------..._...---------•------•---------------------------------------•--- P q P Design Tank—Li uld:ca ac1 .............gallons per person per day. Total daily flow......................................._----gallons. ' 'ty_'_.____-_._gallons Length................ Width................ Diameter_____________._. Depth................ Disposal Trench—No_ ___________________ Width.................... Total Length.................... Total leaching area...............:....sq. ft. Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results' ".Performed by.......................................................................... Date........................................ a Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2............_...minutes per inch Depth of Test Pit____________________ Depth to ground water________________________ Phi --------------------•-------------------------•--•-----••--•-------•-----•------•-----------------...-----•-•-----._...---•--------•---------....._----...._- O Description of SoiL____________5 -------------------------- ----------- -------------------------------------------------------------------------- ------- --------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable.__ - i_ __Q __ivy__ Wjd1.�•�Mc"_____________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with r'1T r'1'- the provisions of,.-7 ?.7 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issged by,the board of,,I alth. n Application Approved,By---- , �--------------------------••••-- ----•--••5 -------------- Date Application Disapproved for the following reasons:________U__________________________________________________________________________________________________ -----------------------------------------•-------...----------------------•-----------------------------------------------------•-•----------••----------------••--------•----------•---•-----------•--- t: r/ ate 'Permit No....... 3- =-�1--�`------------------------------------------- Issued.----.....----- oeo---------------•---- f' °Date • i THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH .....................10.$.M.........OF...............�+rdaisblP............................................ Turdifiratr of Tompliana THIS;JS TO CERTIFY; That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by A. _l a gal_ �. t #¢ a -- t € :aw---MA---- ,26036.................... .---------- Installer at....3.228 Ct3igville %acn-Rd a, -C®� a. 5 , a 026 --...,.:_.*k4=-__ e11-V1ntM--------_---------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the AiF application for Disposal Works Construction Permit No-------- - a'_y7.%--------- dated----------5/28/80_____________________ 4 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A, UARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY �f DATE.... !�'� �''a t r":h: insp'ector � 1.k .._._ •.-cw ".,' -PYT - ,.a....s":5�+,.�.tiic a...++ .�....�w..+.•�...ao.:�+��'ar..awx..�'�e....Ha„ e . _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH p0A�� ............................. FEE._ .. sQQ.. No.................... .... ... T. U!�Vnsa1 Works Tnns#r ion rrmff �Ierm>sslon is hereby granted-----------------------------�-_-..__ ..__ C�.o._.128__XpS_.�.in-eaen,¢-.kl 8........:... to Construct -) 'or Repair ( ) an Individual Sewage Disposal System at No........ ,28 i: 3:1ah_. .:�.__ a11t3 ,�s--S,' ---92 � 3I._� 31 .Q ..__ treet as shown on the application for Disposal Works Construction rmii q 80 _______:__ Dated___.__._5/ / .....:........... Laf"......�-=-`--=. ---'--------------- ................ ? Board of Hpa DATE............ ............................................................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS _ •µme. L