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Home My WebLink About0010 HARRISON ROAD - Health 10 Harrison Road (Centerville) A=229-067 llI/I/Ie(ll�. UPC 10259 No. H1630R HASTINGS,MN 6 • f 9.3L9- 0 - - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is Centerville V Ma 02632 5/24/2021 required for every page. Cityfrown 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 forms A. Inspector Information 6Wr 1 154f 10 on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Sepuse tic Inspection ke the return Company Name Y 74 Beldan Lane Company Address Centerville Ma 02632 Cityrrown state_ ._.....___� Zip Code . 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonesbtle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails -' 5/24/2021 Inspectors 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts J_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road Property Address _ Robert&Suzanne Hallam Owner Owner's Name information is required for every Centerville Ma 02632 5/24/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6. 1) ,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: The property located at 10 Harrison Rd Centerville is served by a Title V septic system consisting of.a 1500 gallon septic tank,distribution box and a perforated pipe leach trench.Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) 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 exfrltration 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): l5insp.doc•rev.726/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road Property Address Robert&Suzanne Hallam Owner owner's Name information is required for every Centerville Ma 02632 5/24/2021 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.uoc•rev.7Y28/21118 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not fior Voluntary Assessments 9 Y rY 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name _ information is required for every Centerville Ma 02632 5/24/2021 tY page. Ci /Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 tfikisp.doc.Pev.71261201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is required for every Centerville Ma 02632 5/24/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems:(cont.) Yes No ❑ ® 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: ❑ ® 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. O ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 11 of a public water supply well t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Swage Disposal System•Page 5 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road `may Property Address Robert&Suzanne Hallam Owner Owner's Name information is Centerville Ma 02632 5/24/2021 required for every State Zip Code Date of Inspection page Citylrown C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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 NIA) ® ❑ 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. ® El approximation 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)] t5insp-doc•rev.7/2612018 We 5 official Inspection Forth:subsurface sewage Oisposal system•Page 6 of i6 Commonwealth of Massachusetts wjwTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is required for every Centerville Ma 02632 5/24/2021 page. - Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 -- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection [] Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date 0ursp doe•rev.7/2612018 Title 5 Official Inspection Form:SubsuAace Sewage Disposal System•page 7 of 18 c Commonwealth of Massachusetts - z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is required for every Centerville Ma 02632 5/24/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No ❑ Non-sanitary waste discharged to the Title 5 system? ❑ Yes No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 51201 8 Title 5 Official Inspection Form:Subsutrace Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts lugTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is Centerville Ma 02632 5/24/2021 required for every city/Town State Zip Code Date of Inspection page. D. System Information (coat.). 4. 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): Approximate age of all components,date installed(if known)and source of information: stem installed 10-1996 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1 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.): Joints in good condition, no leakage,vented through roof. t6bup.doc•rev.7Y26=18 rate 5 official Inspection Form:Subsurface sewage Disposal System•Page 9 of is Commonwealth of Massachusetts .. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is Centerville Ma 02632 5/24/2021 required for every State Zip Code Date of Inspection page Citylrown D. System Information (cont.) 6. Septic Tank(locate on site plan): .5 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 1500 gallons Dimensions: 5" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' 2" Scum thickness 7" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" Opened covers and took How were dimensions determined? measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance.water level was even with outlet, tank was not leaking and was structurally sound. t5imp.doc•rev.712 MIS TiNe 5 Official Inspection Form:Substa ace Sewage Disposal System-Page 10 of 18 Y Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is Centerville Ma 02632 5/24/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 8. 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 t5insp.doc-rev.7r.W018 Idle 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page t 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is Centerville Ma 02632 5/24/2021 required for every State Zip Code Date of Inspection page Citylrown D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0.1 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.): Distribution box was video inspected and found in good condition with no rot.Water level was even with outlet invert. t5insp.doc•rev.7/2612018 TAIe 5 Official Inspection Farm:Subsurface Sewage Disposal system•Page 12 of 18 Commonwealth of Massachusetts UIVE Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road _— Property Address Robert&Suzanne Hallam _.. Owner Owner's Name information is Centerville Ma 02632 5/24/2021 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cunt.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1 x60' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelaltemative system Type/name of technology: -- I5insp.doc-rev.72612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owners Name information is Centerville Ma 02632 5/24/2021 required for every page Cityrrown state Zip Code Date of Inspection D. System Information (cant.) 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): leach trench was video inspected and found dry with no signs of past overloading. 12. 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 failure, level of ndin ,condition of vegetation. Comments(note condition of soil, signs of hydraulic fa Po 9 etc.): t5insp.doc•rev.7I28=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is required for every Centerville Ma 02632 5/24/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5krsp.do•rev.T/ISMI8 Title 5 Official Inspection Form:subsurface sewage oisposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is required for every Centerville Ma 02632 5/24/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference 9 Po Y 9 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 35 8 pb AZ 33 1 r3 Z A3 IL/Jo 133 AY 3i G Y 55 y t5insp.doc-rev.7/AMIS Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of IS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is Centerville Ma 02632 5/24/2021 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 1 fee et 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5inW.doc•rov.7126=6 Title 5 Official Inspedion Fomr.Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Harrison Road Property Address Robert&Suzanne Hallam Owner Owner's Name information is Centerville Ma 02632 5/24/2021 required for every ---- page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth'to high groundwater included t5insp.doc•rev.7f WO18 Tilte 5 official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .°y 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 page. Cityrrown 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 forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return key. Name of Inspector B 8r B Excavation, Inc. ,� Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S14595 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 8/11/11 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 inspectov ano the system owner shall submit the report to the appropriate regional office—c)-f&e-DEP Tie""odgi661 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 r�tyaildrks Ko�vlr system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurfae Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 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: ❑ 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-09/08 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 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 page. Citylfown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 page. Citylrown 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 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 '/z day flow t5ins•09/08 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 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 page. Citylrown 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: E ❑ 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 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09108 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 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is Centerville Ma 02632 8/11/11 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 2008 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•09108 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 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 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: 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 10/2/1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20'feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good condition No sign of leakage Septic Tank(locate on site plan): Depth below grade: 5"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: 5'8"x5'8"x10'6" Sludge depth: no sludge t5ins•09/08 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 ,M 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick 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 appears to be structurally sound. Tees and baffles present- no sign of leakage 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 t5ins•09/08 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 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is Centerville Ma 02632 8/11/11 required for every page. Cityrrown 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•09/08 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 w„ 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 page. Cityrrown 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 appears to be in good shape, no sign of leakage or carryover. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8111/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2x60x2 ❑ 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 appeared to be in good shape no sign of backup or carryover. 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 L15in. 8 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 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is Centerville required for every Ma 02632 8/11/11 page. Cltyrrown 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 C p clean r 0 v d T QOwl- A3:: I2- ' I = 3(6 ' C 3.!: t5ins•09/08 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 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 page. Citylrown 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: >10feet 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Harrison Road Property Address Yasheng Ren Owner Owner's Name information is required for every Centerville Ma 02632 8/11/11 page. Cityrrown 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 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 HOBBS&WARRENTM THE COMMONWEALTH OF MASSACHUSETTS FORM 30 C&W BOARD OF HEALTH CITY/TOW N W 14eAL-7 F-/ DEPARTMENT 0 'p ADDRE S /` l / /rP ,ryp GSM l\ ��r�/ OGZ — `�S y SyO� TELEPHONE 9 �EA So ry AA- &JjA L. Address C_*ia"IfiL.iJ_1Lv5ccupant - Floor Apartment No. -- No.of Occupants S No. of Habitable Rooms No.Sleeping Rooms .S ". No.dwelling or rooming units — No.Stories Name and address of owner C,N x p_� SOSJ (2 G9 Q-TC4 !I t-`f- Remarks Reg. Vio. YARD Out BldgL Fences: Garbage and Rubbish c!)vj nJ 01� Containers: V-j v'%S,4 W C are,v 1.� a 04. ,_3 3 Drainage 2AS t�.jG'[ i tJ l/- "[fc-ft aoalc— Infestation Rats or other: 0fca1-1 IV a-ori,- fir.. J14 E LS STRUCTURE EXT. Steps,Stairs, Porches: mr, A ( u I Dual Egress:and Obst'n.: 4f�-T &(J'T P ❑ B ❑ F ❑ M Doors,Windows: C� S C, lee'ON Flo NRoof -:E:,0a^ e I-- I ti/)vw boo/z- LAO Gutters, Drains: So,r4 2 R t a_a0, t-L Walls: t3�1 Foundation: C4 7C 0 (j Chimney: BASEMENT Gen.Sanitation: Dampness: l Stairs: AAV i4ajL1?_V4AN ezQA1z ti 1'-1 & (-1r, '= FLcI0R NG / �_z_ STRUCTURE INT. Hall,Stairwa : L,%.., 6Na 9r^O Obst'n.i-k wC4 20u tw 1 wncsb.-t, Fe IE Q.0LGIE" C7 p Hall, Floor,Wall,Ceiling: OC / rti 4-00 i-.14ae-116 SUO Hall Lighting: 915,n 1410--4 v 2- m*-iA-m_9,p WQ I � � Hall Windows: Ley \ ,o'o Lc> � t. ,t3A HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: / Supply Line: ❑ MS ❑ ST CAP Waste Line: - OO YVI H.W.Tanks Safety and Vents l Iij >� 56C ►•. Z IQ6ilAi tt� ELECTRIC,#L Panels, Meters,Cir.: ❑ 110 M 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: &1-(0 L� i el 0 Ca C/ / DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 . 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink /S,z CIO el- s ! Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: `Totem C,) e&, -Ted Co 0 IE_ CA MAI—� General Building Posted U I-J I ' 'rf-It W' 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 INSPE TION REPO GNED AND CERTIFIED UNDER THE PAINS AND PENALTIES F PERJU INSPECTO TITLE �f��-7H A DATE Zanp, TIME • A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included'in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as 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. r (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). _ ( ) PY h' q (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 Ieadbased 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-lay 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-(_O)shall be deemed-to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner o.remedy said condition within the time so ordered by the Board of Health. `�..s:..:i�r^••�•�+v-^.��+.'...cro: ...s...:,„,rr�+,.na .: _ ' ""M"\an-,^ro+r..•^.Wyr�y,.� r.�,,,..•v'rr#"`�`i,.^+'ri.r.• .,...:,. .w.rM.....-..m rr.rc.-.n,-.�, .. . r .....- TM THE COMMONWEALTH OF MASSACHUSETTS FORM 30 C&W HOBBS 8 WARREN BOARD OF HEALTH CITY/TOWN DEPARTMENT i 5, C*1d► ` �61 ADDRE S /-==�(j�]]/� 1 GSM SvO�`0� 6 ! V LJ 'TELEPHONE !-A SO AV AA.. IF-9 &J-(A I.— Address "-V4A, tt i50VA f�D• Cff�.i"f1-4\j1 t5ccupant Floor /' Apartment No. -- No. of Occupants �57 No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units -- No.Stories Name and address of owner C 1C> r%A-2.i so aL C 3 -rf-4.V(t. Remarks Reg. Vio. YARD _ Out Bld §.: Fences: _ t' Garbage and Rubbish M3 W n1 Containers: tJ U� . ti�sG.>s0F, �`.A'( ►cTlv2 -• Drainage Su r.ap-L it,) LH 11vIi� �aa� r ` Infestation Rats or other: oo f-,� e-ocily-O C00z-1T 1-4 tt.a;.S " STRUCTURE EXT. Steps,Stairs, Porches: _ ,A2 ., rt _ar ;0 Pt Dual Egress:and Obst'n.: j ►[ >^? ou r.0 4 ❑ B ❑ F ❑ M Doors,Windows: (j �� '� _ 1 �. 4AD Roof` &v I —I /V Uw� /iC�' I�[aD/�, ` 44no / Gutters;Drains: A lo- Foundation: rr C P "I'►..r r�,E l S-rc ►Gt 4h ar" ` Chimney: BASEMENT Gen.Sanitation: Dampness: , Stairs: AID &614-IrV-40 N E A1L �7�l✓L� �/ .� . � , i R ti , . fV Ul STRUCTURE INT:' Ha I,St" ►�,,, ► _ , ,, ,�, 6�A�2r•12 P-+~t 0bst'n.L.. .s I tj eoa 1,._. i V4Cs0Vol Fes. QV>t20t49N (40 Hall, Floor,Wall,Ceilin : QC,I` / � -'/Z.c,o o m Hall Lighting: _ if 0 /'1.o4)*04 �ra 2, Mir,�t,q�.�,�a f° ��+•�►� V , ' Hall Windows: l.. ,► + „ r„- � ' HEATING Chimneys: - r ` Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: ` PLUMBING: Supply Line: ❑ MS ❑ STD%,P Waste Line: %A o0"A _ N.W.Tanks Safety and Vents , i i..l V_ f-.7� gC n.. -t fl mina 4 to ,-ELECTRICAL Panels, Meters,Cir.: w ❑ 110 U 220- Fusin ,Grnd.: AMP: Gen.Cond. Distrib. Box: . f, tPL-o"E,Q n►S?/3G ir,,,► A'�/�v £k� � /II.L�, Gen.Basement Wiring: V211 0 L-g t IZ.t L,/ /_) A_SY DWELLING UNIT `Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry ? Den ' Living Room Bedroom(1). Bedroom 2 >� Bedroom 3 Bedroom, 4 Jul. r "Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink <ZQ Gs�1s 4\0 to Stove Bathing,Toilet Facil. Vent., Plumb.,S.anit'n.: Wash,Basin,.Shower of Tub: Infestation a Rats,Mice, Roaches or Other: Egress Dual andObst'n: -To t,4 Pj c3F A2�,S'P 3 �. a tJtE e-A z General BuildingPosted U MZ.j �,- i & -rt 2F-n A,L- 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 F AUTHORIZED INSPECTOR.(See Over): ,t "THIS INSPE•TION REPOR- IS SIGNED AND CERTIFIED UNDER THE PAINS AND r PENALTIES ,F PERJU 1�' INSPECTOR TITLE �¢�9 L?�j X v.S !- :7'O� w A. DATE 2 TIME U� P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as 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 upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. Town of Barnstable �oF s►+e ta�� Regulatory Services IIARNSTAE3LE, Thomas F. Geiler, Director f 39. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 22, 2008 Attn: C.O.M.M. Fire Health Inspector Jaime A. Cabot conducted a housing inspection in response to a complaint. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector(and\or CO detector) violation(s): 10 Harrison Road, Centerville, Assessors Map-Parcel: (229-067) - Smoke detector not working in basement - Carbon monoxide detector not present in the house. h Jai) A. Cabot, Health Irfspector Q:\Order letters\Housing violations\Rental ordinanceUire ViolationsTIRE TEMPLATE.doc t TOWN OF BARNSTABLE BAR-W 4904 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager m - Address of Offender (n 2, ��}A�i `fit. MV/MB Reg.# " Village/State/Zip D e rA RA k `:3 "N 6, -- Business Name � �G/pm, on ,/104 , 2 J20 C> Business Address r` Sign"ature of Enfor"cing Officer Village/State/Zip rota,,: Locatibn of Offense Enforcing Dept/Division Offense . V ►c-:> A t4 G. t I U t,. A t C)u ""! +tin /1 f 2 FactsiU " �C* t - n' i�A � Nr"S 1?-v l'' Pa! , 1�( --t•;2n�; t� ('u w� This will serve only as a warning. At this time no legal action has been taken. It is the )goal of :Town, agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate -legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE BAR-W h-904 Ordinance or Regulation WARNING NOTICE Name of offender/Manager Address of Offender F0 MV/MB Reg.# try ` :. Village/State/Zip � .� sX's s-\ t ' w na,- Business Name ` 44 /pm, on RU4 . 2j20 ,�) a Business Address Signature, of Enforcing-Officer Village/State/Zip Location of Offense -TNi Enforcing Dept/Division Offense i *.� w � J i. J -� "' '" • 'P �9*F.. t r Facts �rJ "� r'.� - {' , = +�;+3 .s � This will serve only as a warning. At this time no legal action has been taken. ' It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate 1'egal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. pFSHE Tp� Town of Barnstable Barnstable Regulatory Services Department AMlmedcaC"P * BA itNS-rABLE. ' O D 9 Ass. Public Health Division O i639, pArFb MAC A' 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL 70006 2150 0002 1042 1061 August 28, 2008 Yasheng Ren 633 Main Street Dennis, MA 02638-1909 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 10 Harrison Road, Centerville was inspected on August 22, 2008 by Jaime Cabot, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.500— Owner's Responsibility to Maintain Structural Elements: There is a large gap between the brick front step and the threshold. The living room window frame is broken. There is a large hole in the bathroom wall and the bedroom door frame is cracked 105 CMR 410.551-Screens for Windows: Windows missing screens, some screens damaged. 105CMR 410.552- Screens for Doors: 105 CMR 410.612- Maintenance of areas free from garbage and rubbish. Trash in the garage was not in rodent proof containers, rubbish was improperly stored outside. 105 CMR 410.351- Owner's installation and Maintenance responsibilities. Exposed wiring in Basement, Bathroom sink does not drain. 105 CMR 410.482— Smoke Detectors and Carbon Monoxide Alarms CO detectors missing from bedrooms. 105 CMR 410.190- Temperature of hot water. Hot water was 152 Degrees; water is not to exceed 130 degrees Fahrenheit. 105 CMR 410.480(E) -Locks for open able windows. Locks on windows were broken. The following violations of the Town of Barnstable Code were observed: 170-4— Certificate of Registration. Rental property is not registered with Town of Barnstable Health Department. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by installing smoke detectors in accordance with Mass Fire Codes and within thirty (30) days of your receipt of this notice. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Citizen Web Request Page 1 of 2 ry TIC 7p, S,7 6:CLti S"fAla�,f�II Citizen Request Management i" Request ID: 22119 Created: 08/22/2008 11:49:10 Status: Assigned To Staff Assigned To: Cabot, Jaime Health Office Anonymous: No Category: Chapter II : Housing Substandard i E.C. Date: 12/15/2008 Created By: Parvin, Lindsay Citations: BARW4904 Health Office BARW5843 Time Worked: 4.50 Response Time: 2.25 Request Location: 10 HARRISON ROAD Centerville, Ma 02632 LLJ Parcel Number: Map: 229 Block: 067 Lot: 000 Request: Tentant found rental property online, not a registered rental. Bathtub doesn't drain, Kitchen sink doesn't drain, No screens in windows. Garage filled with garbage, which is attracting bugs/rodents. Smoke detectors aren't working. Front stairs broken. Can't get in touch with owner. Request Work History: Entered on 08/22/2008 16:18:17 JAC inspected property on 8/22/08 at the request of the tenant, Steven Wosny. Who had rented the property as a vacation rental. JAC conducted a housing inspection and noted violation: of 105 CMR 410 and Town of Barnstable Code ch.170 and ch.353. An order letter will issue to the property owner. Entered on 09/02/2008 09:20:22 JAC re- inspected property 8-29-08 no one home. Observed trash in yard and drive way poste BARW 4904 on house for nuisance violations. Entered on 10/09/2008 15:14:40 JAC spoke to occupants at house Pat Colbert and Robbie Barletta who are now renting the house. Conditions in the house are unchanged since the August 2008 inspection. Tenant's told ml that they are in contact with Yashengs sister Yan Ping (508) 338-3457. JAC left a phone message http://issgl2/intemalwrs/WRequestPrintPub.aspx?ID=22119 1/7/2009 Citizen Web Request Page 2 of 2 to call. Entered on 10/21/2008 08:53:00 JAC will have obtain new address for service of order. Entered on 11/10/2008 15:53:56 JAC spoke to tenant Robbie Barletta regarding trash in road. JAC was told that allied waste removal took the trash cans when they last picked up. JAC asked that Allied be called and that a request for barrels be made. Barletta stated that a copy of the order letter was enclosed with the November rent payment dropped off at 633 Main St. in Dennis. Tenant would like to with hold rent to hire a plumber and repair steps. JAC advised that legal services be contacted. http://issgl2/intemalwrs/WRequestPrintPub.aspx?ID=22119 1/7/2009 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION N d Y F t �e TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 HARRISON RD CENTERVILLE,MA 02632 �� I Owner's Name: CRAIG COOMBS Owner's Address: 10 HARRISON RD CENTERVILLE,MA 02632 Date of Inspection: 4/27/01 FcF Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O..BOX 2119 TEATICKET,MA.02536 Tp g O Telephone Number: 508-564-6813 FAX 508-564-7270 ti qTBgR ?�0� CERTIFICATION STATEMENT yo ATT�e�F I certify that I have personally inspected the sewage disposal system at this address and that the information repo elow 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: X Passes _ Conditionally Passes _ Needs Furtfig r valuation by the Local Approving Authority Fails Inspector's Signature: lit Date: 4/27/01 The system inspector shall submit rcopy 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. Notes and Comments THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****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. T:.I- nnnn t d Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 HARRISON RD CENTERVILLE,MA 02632 Owner: CRAIG COOMBS Date of Inspection: 4/27/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. 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. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a 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: n/a n/a 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: n/a n/a 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: n/a Page 3 of I 1 rr OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 HARRISON RD CENTERVILLE,MA 02632 Owner: CRAIG COOMBS Date of Inspection: 4/27/01 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 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 n/a "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. 3. Other: n/a Z Page 4 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS MENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 HARRISON RD CENTERVILLE,MA 02632 Owner: CRAIG COOMBS Date of Inspection: 4/27/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool �° available volume is less than '/2 day flow i less than 6 below invert or avai Y _ X Liquid depth m cesspool s _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n/a. X Any portion a. the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with ble water quality analysis. This system passes if the well water analysis, performed at a DEP no acceptable q ty Y � 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 _ X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X 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. Page 5ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 HARRISON RD CENTERVILLE,MA 02632 Owner: CRAIG COOMBS Date of Inspection: 4/27/01 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 X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ 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 X _ Existing information. For example,a plan at the Board of Health. X _ 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)] Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 HARRISON RD CENTERVILLE,MA 02632 Owner: CRAIG COOMBS Date of Inspection: 4/27/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents:3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no):NO Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1996 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of t 1 r . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 HARRISON RD CENTERVILLE,MA 02632 Owner: CRAIG COOMBS Date of Inspection: 4/27/01 BUILDING SEWER(locate on site plan) Depth below grade: 9" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:3" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H 5'6" W 5' 8"" . Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.RECOMMEND NEW COVER. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 HARRISON RD CENTERVILLE,MA 02632 Owner: CRAIG COOMBS Date of Inspection: 4/27/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a 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: 10 HARRISON RD CENTERVILLE,MA 02632 Owner: CRAIG COOMBS Date of Inspection: 4/27/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a I leaching trenches, number, length: 60 n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH TRENCH APPEARS TO BE FUNCTIONING PROPERLY. THE SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of 1 I OFF ICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 HARRISON RD CENTERVILLE,MA 02632 Owner: CRAIG COOMBS Date of Inspection: 4/27/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. o A a � f~t beck Sc�e AA 40 AO can A AV ffi IL` 60 i q ✓ Pa.gellofll OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 HARRISON RD CENTERVILLE,MA 02632 Owner: CRAIG COOMBS Date of Inspection: 4/27/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain:n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 10+FEET e TOWN OF BARNSTABLE LOCATION /64 114-M-i®n SEWAGE # (3 VILLAGE ( ' �s• ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. f/� �� SEPTIC TANK CAPACITY /01) a LEACHING FACILITY: (type). A/iwf (size) e;t x �� NO.OF BEDROOMS BUILDER OR OWNER-J � �� PERMITDATE: 9G COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Ll OP Lo ® �- • 4 p No. Fee " THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mi!5po.5al *pgtem Con!5truction Permit Application is hereby made for a Permit to Construct( )or Repair j,_--)`an On-site Sewage Disposal System at: Location Address or Lot No./0 /—A r`%tso to Owner's Name,Address and Tel.No. Assessor's Map/Parcel .� 4Q'M S�t�,— �(Q7 Instal 's N e,Address and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 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 Description of Soil Ann s hg�C� Nature of Repairs or Alterations(Answer w en applic ble �z - 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 a Enviro a ode and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi ar e Signed Date Application Approved by Date Application Disapproved for the 11 ing re sons Permit No. �� Date Issued - i No. - Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for i0iopooal 6potem Conotruction Permit Application is hereby made for a Permit to Construct( )or Repair�N-h On-site Sewage Disposal System at: Location Address or Lot No./O l LsoNAD - Owner's Name,Address and Tel.No. Assessor's Map/Parcel aQ S Ins 's Name,Address and Tel No. � Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons _ Showers( ) Cafeteria( ) Other Fixtures '' Design Flow_ gallons per day. Calculated daily flow 30 gallons. Plan Date Number of sheets Revision Date Title Description of Soil A�III , 6� Nature of Repairs or Alterations(Answer when applic ble) �Z t 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 Enviro ental- ode and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi ofHea Signed Date P0'4 Application Approved by Date /n Application Disapproved for the ll ing re sons Permit No. ?2 .:Date,Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( �n �A by iA . _ C— Installer N at Cc�t,�, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction P it No. -Jt"o dated Date Inspector THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. No. Fee v� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 30iopogar Opotem Construction Permit Permission is hereby granted to to construct( )repair(J-an n-site Sewage System located at No.# ) Street and as described in the above Application for Disposal System Construction Permit. 13-63 No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. Date: /S -�_ - � Approved by Board of Health y' CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL �. WORKS CONSTItUCTION PERMIT(WITHOUT DESIGNED PLANS) 3 `; i, - hereby certify that the application for disposal works , construction permit signed by me dated concerning the r rr property located at ZjQ �' Svc- �i�1` -�rA meets all oft r `Z M following criteria: z hf I • There arc no wetlands within 300 feet of the proposed septic systemh# `i ° • There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching In llity i There is no increase in flow and/or change in use proposedy v , k • There are no variances requested or needed. ° - .. ' rf SIGNED: :E1 DATE LICENSED SI SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER F , �z v} Y45 ."'�'t tv ��{ -z.a _ ,,.p,'C �'at.xtw:r',�,z '4'"� .t�+>rs$d• j-6. V[y , [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a cerUlied plot plan; 3 , ¢ �"` F� °p;xkn this plan should be submitted]. _;• � � ucj vm {#wEj WK A ✓ t 5,n y `� y �-�u�� O D d t TOWN OF BARNSTABLE BAR-W 5843 Ordinance or Regulation WARNING NOTICE Name of Off ender/Manager , , t�-�i. ! , '�t.4 - Address of Offender 10 MV/MB Reg.# Village/State/Zip (�Ir -T r Pad4"4-7 Business Name 1t :'Z,,��amr/pm, on // /b 20nci Business Address J Signature -of Enforcing Officer Village/State/Zip C iF tej 6Z6,97 Location of Offense / Enforcing Dept/Division Offense l? M�_. / �' L _ . � ,R r 2`IJ " .. `� t?/ti► �� Facts N2o PE 4t, -(1N, ,,,a F+2Ca This will serve only as a warning. At this time no legal action has been taken- -It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations.. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. r=1 r--1 fu aPostage. $ Jds� fU Certified Fee p Return Receipt Fee pno7 (�Pos p (Endorsement Required) CU 1i�t 9 2 C3 Restricted Delivery Fee p (Endorsement Required) rq Total Postage&Fees $ �Y rU Sent To ..... p Street,Apt. o.; or PO Box No. M A6� S , 3 ...................... ---------T .................... Certified Mail Provides: f ■ A mailing receipt A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: 4 Certified Mail may ONLY be combined with First-Class Maile or Priority Maile. ■ Certified Mail is not available for any class of international mail. ® NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. e For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. f a For an ,additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for'postmarking. If a,postmark on,the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt an iiresent it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02.000-9047 i THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA . � _ �i __ ,. ... r.. � TOWN OF BARNSTABLE BAR-W ordinance or Regulation WARNING NOTICE Name of Off ender/Manager Address of Offender MV/MB Reg.# Village/State/Zip r Business Name tk - -kj ,-ap/pm, on 200 o a U V5 Business Address . Signature of Enforcin4 Officer Village/State/Zip ► iF tj Location of Offense Enforcing Dept/Division Offense I LI, Facts 'v`�. L This will serve only as a warning. At this tiihe no legal action has been'-taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations.- . Education efforts and warning notices are "Attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DE T) Jr SHE Town of Barnstable Barnstable TOk'1. Regulatory Services Department ;edcaC"j IIA.RNS-rABGE. ' D MASS. 9 Public Health Division �`1] '°rfo MAC a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL 70006 2150 0002 1042 1061 August 28, 2008 Yasheng Ren 633 Main Street Dennis, MA 02638-1909 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 10 Harrison Road, Centerville was inspected on August 22, 2008 by Jaime Cabot, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements: There is a large gap between the brick front step and the threshold. The living room window frame is broken. There is a large hole in the bathroom wall and the bedroom door frame is cracked 105 CMR 410.551-Screens for Windows: There are windows missing screens and some screens are damaged. 105CMR 410.552- Screens for Doors: There is non screen o n the sliding door to the deck. 105 CMR 410.612- Maintenance of areas free from garbage and rubbish. Trash in the garage showed evidence of rodent activity, rubbish was improperly stored outside. 105 CMR 410.351- Owner's installation and Maintenance responsibilities. Junction box in basement had exposed wiring, Bathroom sink does not drain properly. 105 CMR 410.482—Smoke Detectors and Carbon Monoxide Alarms Carbon Monoxide detectors missing from bedrooms. 105 CMR 410.190- Temperature of hot water. The hot water temperature was 152 Degrees; water is not to exceed 130 degrees Fahrenheit. 105 CMR 410.480(E) -Locks for open able windows. Locks on windows were broken. The following violations of the Town of Barnstable Code were observed: 070-4—Certificate of Registration. Rental property is not registered with Town of Barnstable Health Department. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by installing smoke detectors in accordance with Mass Fire Codes and correcting the violations listed above within thirty (30) days of your receipt of this notice. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable