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HomeMy WebLinkAbout0449 OLD CRAIGVILLE ROAD - Health 449 Old Craigville Road 4 Centerville P A = 247 037 i II �ACYC(foe"oy� UPC 12534 ' No.215�oR �„ HASTINGS,UN •y I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 449 OLD l:RAiGVILLE RD Probe Address cgeg Owner Owner's NampLq information is CENTERVI LE required for MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness,checklist at the end of the form. Important:When filling out A, General Information forms on the computer,use 1. Inspector: �� only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityr town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addressFand 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 -rr r sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 o, Title 5(310 CMR 15.000).The system: r ® Passes ❑ Conditionally Passes ❑ Fails CO ❑ Needs Further Evaluation by the Local Approving Authority yr rn 10/15/09 spe ignaW. Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within An riavc of rmmplafinn fhi¢incnar4inn If the cvcfam is a chnrarl cvcfam nr has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under " uia s am.a or rant conlu LIo.-,s VI uaa. t5ins•09N8 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ✓� � r TOWN bF B-AMSTABLE e L,riCAT?ON �� ltXl.�a� ✓�1S.e, S WAGE # VILLAGE S S MAP & LOT ©� INSTALLER'S NAME&PHONE NO. i SEPTIC TANK CAPACITY LEACHING FACILrTY: (type) \ (size) Or")CYM NO. OF BEDROOMS ,,\\ BUILDER OR OWNER ow-kO'.V" ''W PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by -•_ i `��.; �5� �� , d� . _ .. �� ' �. Commonwealth of Massachusetts m .ri TC�IA C I ■7T�A�AI INA NAA��AN cone 4 I ILIC v VIMPIQI IIIOIJC%,LI%J I VI III Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information is required for CENTERVILLE MA 02632 10/15/09 every page. Cityrrown 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: I I AU 1 MIT If+ 1 IAI r rl 11 1 AT TI 11^TIAAr\A/1TI 1 [\TA 1AI IA 1r AT 1 1/\I I11'1 1 r\I.-1 LL/1VI1 rll IJ -nL1 FULL IIIIJ IIIVIL. VVI IIIJI^IIV LIIVL n1 gal'JI✓LL.VLL 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•091D8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 1 T Commonwealth of Massachusetts TA21=1 TC6Iw C n#iwiwl Ir�e"r�ww�i�►r� l=0% SW% 1 ILIC v WIIILr1A1 11101„ OULIVII 1 VI III Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water ievei 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 ❑ "Iesspooi or privy is ivii'iii'IV fc@t of a borderu'y'vegiated 4'ieiiand or a salt r-narsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts r:4.1.. C t \ �A�AI INA NAA��AN CAM�7/\ 1 ILIC v VIIILr1Al IIIOFCVLIVII 1 V111i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `t 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, saf@ y ar1U ar1Y1r Vlllllent: ❑ 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 � .....I„..,gin ❑ 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 Ic55 ii18i1 5 NNi1i, FIIVVIUCU llldl IIV Vl1I IdiillrC C11ii@ii&are iliggeied.A wpy of the analysis i1iustt ue attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You musi indicate'`Yes"or"No"to each of the foiiowing for aii 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 vu--to ann VYe-riVYdVd or clogged SAS o W 1 as ssp�o, ❑ ❑ 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 Yz day flow t5ins•09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealltthfo�.f Massachusetts T;4.I/A C / .TI�A�AI INA KAA��A,N CAM�M I�IC v Vlll�rlal 111.�1, t./�it�41V11 I VI III Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information CENTERVILLE required for MA 02632 10l15l09 every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Reauired 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 oresence 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. 17-1❑ 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 2uu feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered'yes"to any question in Section E the system is considered a significant threat, or answered`yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 4 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ®y%~ 449 OLD CRAiGVILLE RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate'fires"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 buiit pians 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? ❑ ,n .^.r�r@ wllSystem. ^ pcn„ .s, excluding the SAS, �.. .+.ea:�� ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms !design)- 3 Kh rmhcr^f hcMlr _mc/ae+inl1• DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 :4 Y Commonwealth of Massachusetts m � ■1 ILIC v VIII%rIQI 1 ICFJCVLIV 1 CV11 1 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °~ 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information is required for CENTERVILLE MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS BUILT SYSTEM CONSISTS OF A 1000 GALLON TANK AND A 1000 GALLON I r-Anu PIT Number of current residents: 2 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 08-164/07-132 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENT P Date Commerciaiiindustriai How 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•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I � \ Y Commonwealth of Massachusetts m m TCi.I.. C • 1TlIAIAI INA NAA�IAN C0%WWW% 1 ILIC v VIIIVIQI III01JVULIV11 1 V1111 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information is required for CENTERVILLE MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date VLItCf(Ut3Jli11UC UCIUW). (Unaral Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No if yes, voiume 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): TANK AND PIT NO D-BOX t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 x Commonwealth of Massachusetts Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information is required for CENTERVILLE MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Curiiriierii�(uri curidhion ui juirii3, verliirly, evidence ui leakage, eic.). Spntir Tank flnratP nn cites nlanl: Depth below grade: 2 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: years is aye wnilrrned by a Ceriificaie of Curnpiianc e-,(aiiduh a wpy of certificate) ❑ Yes ❑ Nu Dimensions: Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t Commonwealth of Massachusetts m !-n T.�IA C / l��A�AI INA NAA��AN CAMrM 1 I<I�i v VIIIVIAI III.7NC�rLIV11 1 V1111 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'f 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name ing required is CENTERVILLE re wired for MA 02632 10/15/09 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from iop of siudge to bottom of outiet tee or banie 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND RISERS ON TANK AND PIT Grease Trap(locate on site plan): Depth below grade: feet iviaiei iai 01 c insii ucii011. ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: jGUlll ihickrjass 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 Kina.f10R1W Tito 5 Cu.nno DsMal System.Dann 10 of 17 Commonwealth of Massachusetts m rn T'��IA C • • �A�AI INA NAA�IAN CAW*'W% Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name inf ormation is CENTERVILLE required for MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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: Li Wflu eie ❑ fiiei8i 'J -- ^ ^ L__I nuefyfas� Li p�iyeiiryiQfle LJ uiiiei(cxpiaifi). Dimensions: Capacity: gallons Design F iow. 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 i Commonwealth of Massachusetts n, rn T��.I.. C I 177��A�AI INA NAA��AN CAMYM I ILIa v W111%pial 1110FUt-uv11 I v11111 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 10/15l09 every 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 ievei above ouiiei invert 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.): Pumn Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, of pumps and appurtenances, etc.): $Ail Ah$nrntion RvsM_m(SARI(In rat-on$itA Man, P_.Xravatinn not rP_.nllirp_ri)' If SAS not located, explain why: t5ins•09)08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f T Commonwealth of Massachusetts m � I ILI= V viii1hPiai IIIOFC%.iivli cvii i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information is required for CENTERVILLE MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: �^ 1 Ibl leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system i ypeiname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): PIT IS @ HALF FULL WITH STAIN LINE AT LIQUID LEVEL RECOMMEND RISER ON PIT 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 w,e-w;W o... abec mace aewaye u6p:Wal3y6wF.-.•page of I Commonwealth of Massachusetts ^ern C r ltl4WE*A0*AI INA NAA��AN CAMMA 1 "SIC V W I MPIaI Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 449 OLD CRAIGVILLE RD Properly Address Owner Owner's Name information is required for CENTERVILLE MA 02632 10/15/09 every page. Cltyrrown 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 Depiii Oi SOWS Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r ,1 Commonwealth of Massachusetts mrn 'rt6I.. C ■ IIA�AI INA NAA��/�N CAMrN 1 ILIC VIIIVIQI III�r,JCVLIVII 1 V1111 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate -OvIllcrc Nuuiw vrmcr Sul'R'l7 cniclo uhc building.Il,. VIIGVk one of ulc Vvnco vcwvr. ❑ hand-sketch in the area below ® drawing attached separately 3� 2'L ` 8 t5ins-09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts T /T 1r:4.1A C �1#'.A:..1 I-NA NAA��wN CwrrN 1 ILM v V111Lr101 III0jJCVLIVII 1 V1111 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information is required for CENTERVILLE MA 02632 10/15/09 every page. Cityrrown 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: 4FT++ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record if checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must deSCriha hnw vn,,acfahlicharf fha hinh nrry inrl wafar alavnfinn- Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts mom T���c .P v111a.1a1 I 0NWa.L1v 1 cv1111 F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 449 OLD CRAIGVILLE RD Property Address Owner Owner's Name information Is required for CENTERVILLE MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ILSI Inspection Summary D(System failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ��6�VV■ rev SEP 2 4 2002 . COMMONWEALTH OF MASSACHUSE.TTS TOWN OF BARNSTABLE HEALTH DEPT., EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION PARCEL. A 03�_ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Q el I ( /'O/' y',Ile �� ^ o r� t y 3� Owner's Name: 1 a h l.�e Owner's Address: rr rv,/e o26 Date of Inspection: a 7 Name of Inspector: ( lease print)` P Com any Name: Mailing Address: O XatV O.�-t; 1 Telephone Number: o 7 --2'I 44�" CERTIFICATION STATEMENT I certify that I have personallv 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: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Sign atu Date: �$ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater.the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable.and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:� � �J C�� l�r� ied Owner. Date of Inspection: j� 4? O A, Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Svstem Passes: V 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system.upon completion of the replacement or repair.as approved by the Board of Health.will pass. Answer yes,no or not determined(YAND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound exhibits substantial infiltration or enfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken.settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: J CEO, -Vo /(_o<:;? Owner. _ Date of Inspection: Y 2 7 O-2- 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 I 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 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. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: OP " r P `/� r. Wei Owne a Date of Inspection: 7 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 — logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or of Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ v 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 supple or tributary to a surface /water supply. _ -� y portion of a cesspool or privy is within a Zone 1 of a public well. �� � y portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis. performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria ��/ are triggered.A copy of the analysis must be attached to this form.] A" y (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CUR 15.303.therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat. or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: q q of cr'GI i Vv 1 j Owner: ye Date of Inspection: �19 Obi Check if the following have been done.You must indicate`Wes"or"no"as to each of the following: No Pumping information was provided by the owner,occupant.or Board of Health _ ZWere any of the system components pumped out in the previous two weeks ZHas the system received normal flows in the previous two week period ZHave 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 v _ 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: Yew no Existing information. For example.a plan at the Board of Health. v — 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)) i Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_�� d C/'O, .v,Me Cep rvz ei ./� 0�6� Owner. (,✓ems Date of Inspection: ? t7 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: / _ Does residence have a garbage grinder(yes or no):/VO Is laundry on a separate sewage system((yye�s or no):/IV [if yes separate inspection required] Laundry system inspected(yes or no):AlO Seasonal use: (yes or no):�S Water meter readings,if available(last 2 years usage(gpd)): a00 p— d-)pay d200 / 0 DSO Sump pump(ves or no): o Last date of occupancy: -64I�GY► COMMERCIAL/INDUSTRIAL Type of establishment:. Design flow(based on 310 CMR 15.203): JZDd Basis of design flow(seats/persons/sg8,etc.): Grease trap present(ves or no):_ Industrial waste holding tank present(ves or no):_ Non-sanitary waste discharged to the Title 5 system(ves or no):_ Water meter readings.if available:. Last date of occupancy/rise: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ��U Vy lie,`�- -- 13Ag i Was system pumped as part of the inspection(ves or no): If ves.volume pumped: pllons—How was quantity pumped determined? Reason for pumping: TYW10F SYSTEM V/ Septic tank distribution box, soil absorption system _Single cesspool Overflow cesspool Privy Shared system(yes or no)(if ves,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): Approximate age of all componen&& date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):/✓� Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:0 '1 bra m zx Owner. IV&k2b Date of Inspection: BIIII.DING SEWER(locate on site plan) Depth below grade:' 30 Materials of construction: cast iron y 40 PVC_other(explain): Distance from private water supply well or suction line: • Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: a 6 Material of construction: concrete_metal_fiberglass_polvethylene —other(explain) If tank is metal list age:_ Is age confirmed try a Certificate of Compliance(yes or no):_(attach a copy of certificate) Sx� Dimensions: Sludge depth: 3 ./ Distance from top of fudge to bottom of outlet tee or baffle:3/ Scum thickness:� Distance from top of scum to top of outlet tee or baffle: --/f'd .SC •"7 Distance from bottom of scum to bolt of out tee or baffle: — No How were dimensions determined: c:�e ���., cje v/r�, Comments(on pumping recommendations. inlet an outlet tee or baffle condition structural integrity. liquid levels as lated to outlet invert. dense of leakz�e. etc.): h t J GREASE TRAP:'L-Qocate on site plan) Depth below grade: Material of construction: _concrete_metal_fiberglass_polvethvlene other (explain).- Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations. inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: fLI / old Cf� l✓ille � l Owner. Date of Inspection: TIGHT or HOLDING TANK: 4 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction concrete metal fiberglass_polyethylene other(ekplain): Dimensions: Capacity: gallons Design Flow: gallonstday Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches.etc.): DISTRIBUTION BOX: IV(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal.any evidence of solids carryover,anv evidence of leakage into 0 outp box.etc.): U U?C G✓+C" / ' f1 of, C�YZ L PUMP CHAMBER /f/ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances.etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) O Property Address: "9 /C Owner. 6ve44 Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: T � y 10 leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,.number: mnovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation. etc.):Q T' CESSPOOLS:AL"(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 laver: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil• signs of hydraulic failure. level of ponding,condition of vegetation,etc.): PRIVY: ovate 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.): l r Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 �:'� Zvi �� Owner. b V Date of Inspection: p 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. j: 114 G d I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q c V4 Ile �J ro/le, Owner. Lyee,.� Date of Inspection:. SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water I �• feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) �hecked with local Board of Heal w✓► s th�xpL•un: To Checked with local excavators.installers-(attach documentation) Accessed USGS database-explain: You mush describe how you established the high ground water ele tion: r� J­> ------------ 1� �r,71�'rii/•i � J i A ( / u COMMONWEALTH OF MSSACHUS ETTS EXECUTIVE OFFICE OF' PR ENVIRONMENTAL AFFAMS T ON DEPARTMENT EloiVl]���+ ONE VnNnR $MET,BOSTON MA 02109 (617)292-65D TRULY MM (lrK»tary akvil)R.SMUH9 K,t(;ZO PAUL CELLUCCI �^asstioisaioaer Gave BURS J9lPACE SMAOE DISPOS .Sys I t PEC?!OM POIIIMF PART A CENIMPICATION we ar As+ r..: .1 Q/�G- ' �llP 2dI NM 0 of 4axoFix�� f+9st8s i�eas� . It mom?of Ms .—.diMsss�M+eb„ U X/ �e . �}a/ �Y 1 or,►o 10 s>41doae 1 S.Sl0 of Me 5(310 COW 15.000) memo Aodsiriusa: Teisphow Mittwibw': - It '.M WATRIMM 1&wtfy chat 1 hsvo personally inspeectod the sewage disposal system at this address and that the infonnation reported below Is rus.ecat,ate and cornplot!,an rrl the time of ims9e000. The inspection wee performed bated on my training and experience in the proper kittgon ewul meantenence of on-sits*swage dlspoeal systems. The system: Pesees r... cesiodonay Ihases IMesds Further Evaluation ey the Local Approving Authority Fans a�g�- eagpaator'a I IEnaaae: _'�C�� Doss: Thu 1411tam Insipector ahall submit a oopv of this inspection report to the Approving Authority(board cf#eaft or DEP)wt wn tfa rty (Sol they@ of co•W1e0140 VIls Int.peotion, ff the system Is a shared system or has a dasign now of 10,000 gpd or gr,later,the Inspactor ant b�is systatn owner shall subrnit'tie report to the aWopryrte regional office of the Department of Environmental P►otoctior. The original should bo:i#nt to,ihs s"tam owrw!a and copies sent to the taayer, if applicable, and the a®provUvg authority. wini! AND CC1Al MIMIT6 rev,,jeed 4/2/9e pop 1ort1 Printtd on ftCWIVd Paper 4 SUMUiRFACE$2WA4W ONFOSAL SYSTEM MpECnm Fmil PART A CIRMICATRIN isondwaM OWAV eLAO Deftl ial`aru!lkitlot iMSPEe."TM 141111MAlRY: Ch" A, A C, or 0. A. VIPS EM►A@Sn: I hsvu not found any irrfo MUon which indicates that any of the fedora conditions described In 310 CMR 16.303 uxhit. Any fauuoe cliterim rat evaluated are ind Olted below. ti. EY=T®R 4;018DITIONALLY PA*=;: One a►more system componerft ao described In tM "Conditions ess"soctian need to be r completion of the replacement or repai►,as appZ'* d of Idsaigi,will peso. replaced or repaired. The ov es►n,, uiaon hrdlkane yes,nit,or nst datorttlinad fY,AI!,sr MD?. Do3crdnatiien in ail instances. If "not determined",explain vvisy not. The septic tank Is metal,unless tM oao providod the system inspecto►with sC�s'mpiiance lattocheel Wsocathv thatm&W wieNn twenty(20)years;srior to the date ofathe�nihaa"�rt the septic tank,whathor or not ,is crooked.atrupWrOy unsound,shows substsittiel ir!MirlIon w eattittra;ion,at Urik failure is NnnrrMnent. 7'hs syote II pass inspection If the o:deting septic tank is repia.ed with a eomplyiei0,lei tic tm+N a� 4160roved by tins hoard W H /i:nv�pmlklon brnshout or high stoic water isvol observed in the distribution box s duo to broken or jWwrcM.clog p4!pw!$I settled or uneven distHbution box. The system will paws Inopactiol:if{with opproVal of the It , of rcoksn pipsls)sire ropboadb noiadon is removed hirlbution box is Iovaged or►epiaeed pumptmg endue elan four times sYssr due to broken or obstructed RtpMs). The systern twill posepproval of OW Hoard of Health): roken plpals)are replaced! obstruetion k removed revised 51/2/98. Fwaat11 gt111 UMACE SEWAGE DIS►O"L SVSTM MXpeCTM p Mlli! PART A CSSTIi7ce6T1®111 le�exxrresod} .r" 1�vL wg 1w Crr 5 fie ' o.$.ateRlan: $ Na ct(w C. Fti;IRTHE1t EYAI,I ATMN 4 REOUIFID gy THE•owA1tD OF HFALTH: .,�— Condito w exist whkh ro4xirs further sveiustion by the eoard of Meei'th In Ord determine If the systems is falling tO lirot*;t Ito Publk hu",safety and the a,wUonmem 11 SVS1'HA WILL PASS UNLMI BOARD OF HMTH DMraNn IN 91AYT1f 310 1011fR 15.3A3 411tM)TFIAj1!'THi:8yiETM IS WiT 1$AMCTI ImC N A MAR,MN WNM WU PROTECT FSLIC HEALTH AM 3ARTY AM THE IiEf1/1 uXVM'iMT: _,,, Casepool or plin Is%wid re so foal of surface wet C-068POCI or privy is%Wthin 60 fast Of a vegetated wetland w a Salt marsh. 31 S1rST1:lId 111 U FAIL UNLM PDARD OF HEALTH(AND MMUC IVATM SU F ANY) TMiT TiHiE SYSTEM E FtNW"1Oil1M 0 A 'HAT MOTECTR THE FUNM HEALTH AND SAFETY AND THE i _.. The system S Sesge t$nk and soli ehsorpelon system(MI)and the EA?is witMn too feet of a surfecra arts er��rxgt9"or tributary to WOW eLnhply. — The s has a aspic tank and Boil abaw112161 System and the SAS to wtoon a Zone I of a oublic WOW®u;�e1 r well, _,. The a Ms a 414ode tank and$oil absorptlen system and ties SAS is within 60 toss:of a privets water supgo'l wse. The tsm has a sep+de tank and$Oil abewptien System and the SAS is lose than 100 feet but 50 lest or roes from a PH water Supply errtll,unless a well water sn*w@ for confirm bsaterla grid vOletl4t�orSania Compounds irwo,;&"S Ogt the w Is free from pollutk�t from that fasigty and the presancsr Of ammonia nitrogen and nitrate nitrogen Is o%jei ie w isus m i ppm. Misdwd used to determine distw4w (apprealmadon not valW1. 3) OT rev: Sad :+/ i 98 B1ge3sf11 SUNSURFACE SEWAGE CBPOGAL SMW MPWTM l>OA (PART A t OMINICATM(oentlnraredl oCG9 Cf o '(t Owroer; � � 4�` � «►iainiotaall.mt: g��4 �� D. 84FSTM IfAU: YOU nxeet Indk;M either"Yes'or"No" to ouch of the fallowing: �.,_. i have dets"nined that one or tnofe of the following failure eanditions axis described in 310 Ci41R 15-303. The bssle for hlr dotw+ednatlon U ldmetifi*d bola*, The Board of Moakh should be corm to determine what will be necessary to corroot the fau�we. yes No leokup of sewage into f*c"or eyetem componont to on overloaded ar clogged SAS or ceespoei. VIWhage or ponding of effluent to the surface the groun41 or surface waters due tv an overloaded or cIVIlgaI$AS cir tesspooi. Static atluid level In the distribution bo w outlet Invert clue to an overloaded or ol,)Wdl$AS or cesspool. UgWd depth in cesspool is lose •"below invort at available volume Is less than 112 day flow. Risquirad pumping more th times in the last.year JW du*to clogged or obstructed pipets). N'Vft r of times pumped — — Aaey portion of the I3 Absorption System.cesspool or privy Is below the high groundwater elevation. — — Any portion of essiwal or privy is within too feet of a surface water suPP1Y of tributery to a surface water sitppiy. Any ports !a cesslecal or privy is within a Zone 1 of a public wed, „" Any en of a cesspool or privy is within$0 feet of a private water supply era#. __ portion of a oessilool at privy is leas^lhan 100 feet but greater than $0 feet from in private water supply wail with tmb eccaptebi*water QUI RY analysis. It the wolf he$been analyzed 10 be acceptable: etch copy of wall ws+.:or an:plysls few collt M bacteris, valagie organic compounds,a nfemm a nitrog�r ind nitrate nitrogen. L aai M SV EIVW FALS: You neumtt kedlomite sigur"Yea"or"No" to*Soh of the faffowi The it 4atatrig criteria apply to large systems in tad en to the crRorie above:. The s-,stem serves a facility wipe a desig w of 10,000 gpd or g►eatsr(Largo System)and the system Is a signlficant,tie root to public health and tiefsty Bred the onvlronme sus*one or more of the following conditions exist: yes No .,_ the system n 400 fast of a surface drinking water supply w the Is within 200 feet of a tributary to a surface driwkiing water supply Z'16r systemsislocatedeanitrogen sensitive Brea(interim WNihpd Protectiem At" I%VPA)er a mapped 2(mul tl of a pubmin water Supply wee) The o�� ,Rtc r of any such eyaterri Shea upgrade the system In accordaru:s with 310 CMR 11.30r42). please coraruft,the to:al regilwwd oifiafOf the ttairartmnamt for thither Information. reviiged 9/2/38 Tojosof11 l6USSURFACE SEWAG&DOUNW L SVIIT111111111 MSPECflOM POM PART S CHECXLWT Ap�t�I `��/ cd e"' fi/< to as"off, I,Rion: q00 I Chows li`tho followirel'have been done: Vou must lnricate ehher"'Yes' or""*" Soto each of the following: No Pernpilieg Information was provided by the owner,occupant,or®card of J+aa14h. Nana of the system components have bean pxrped ter at Issot two weeks and the sYstsm has been t dvifgl Forma)Sow rafts during that period, Large volumes of water have not been introduced into the systern recently or sit port of this As bunt plans have baron obtained and examined. Note If they we not available with AIIA. _ Tlia facUlty or dwelling was Inspected for signs of sewage back-up. The system does not receive non-sanitary or irwdustriel waste flow. The aft was lnspeopld for signs of breakout. AN system components,excluding the Boll Absorption System,have been located on,,%*site. w The*optic tank manholes were uncovered,opened, and the interior of the @optic tank woe inspected for condtion of baillss or tsw material of construction,dimensions,depth of Uquid, depth of sludge,depth of scurn. The size and location of the SOU Absorption System On the site has been determined kissed on: Existing ktfamatlon. Igor exampis,Piave at 0.0.". _ Distsnnined In the fldid Of any of the failure crherie related to Part C Is at Issue,approsinration of(gstanee Is umicceplabi@) t 15.302(3)(b)) The ba ty owner(and occupants,If dlffsrenot from owner)were provided with informstion on the prong iraint,rnanoe of Sub3urfaee Diapesel liyattees. revived ,3j2f98 hplefll SU&S UNFACE SEWAGE WIUOSAL SY:STM NSKCTM FORM PART C STSM BWOQAWATMU - n„ey ^� �f�Craec�✓c ��� Q4 Owwor c �ass I�Poo i6an:���Cw PLOW CONDFTKM6fi ®ssh;ln flow:,o, B•p•d•Ibed►sam. NurMw of bed:loc ( ):�Z Number of bedrooms(actual):3 Tow!MtON'Jlow wiftbal'of cw'sm nrddsrw:l� 6iarbep 9rindl11 IV" of no): w 6eumdrly(aapersen$11140ml lyss a sal:,_; If yes,separateinepectiois rebLIrad � Leun,Ont eyawlu insp �s or not sesaar�use I Io$or n0) Q S Wour meter nndnpe.If able past tovo year's use6s 190): _ Bump Wmp Ivive or rai:_ tv Last este of a ouptanvv.7iZ-040 i Type of esabl ahnsnt: O"gn flow:., osid ( Based Z.1031 Bests of dseip,ft iw► Grofts troy pn1ssrtt:(yes sr no)_ (trdua roriai Wsr+Mo1 llnB Tsryc pro :(yes a no)— Non•isentltary writs 4kaher the THe 6 system: (yes or no)_ W&M meter madinp,H Lost/eba a or cope OTiHEft:l9ssc� MATION P+t=MlIA IMIXM end sow of mstion: t9 . � rat` n 1./1� Systilm PUIV00 es part of inspoction:(yes or no) tf Vol,valume pumped: —BaMene Itees:sr for pumpkV., I(MIM So O.,tmUadletwilowiso4owson absorption system _...._. "o Caladpoo+ �,.,. Over low cssepesl py Shenod system(yes or no) (If Vivo, attach previous inspsotion recorde,if any) UA Tieohato1M'sba.Attach copy of up to dsts operatien and maintenance contract T*1 Tank Copy of DIM Appmoll Other APPAIRplfxf YI:;AM of eN ownponents.slate in$"Ud(If known)end source of information:_-*t1rW Acts MP ealsfe-btwMd when enlvft at,the site:(yea or no)!' revised 9,/2/9t3 hp6oftt SUUURPACE SMMAt1E DEP06"SrSTpA N=PECTWN FORM PART C BTS'TBA mopoQMATiomi(eenfinMod/ ago of I 11 Mr. Q� @mom flSbl,f!!t: (Loom an site Man) Depth sole*onrds: i Sr OP Mural of eoni.aNetlen;_oast iron 4.so PVC—othw(exFaln) Dfsunea 'ZVMm wet dl or or supply w auction One Dwnorta Cerrrnwnu:(aa iltlen of joinb,von*V, evidence of loskoes.ate.) OMPTORiF (110001e en sits peen) t'r Depth h in snide:v�� Meted d of aM'ftatean: concrete�_lnow wHbergtsss _Palyethylshe_**erlexpain) Of W* is rased, Rn efio Is Poe confirmed by Certificate of Compliance (yes/No) "WOO dtpEh: _ IleDistenes,from trip crl 1 dge to potter!of outlet too or ba4Ao:=a Scum Pi cknea: / ' f/ or Dissan os from tc p of doom to top of autbe tee or bof}Bo:0 ee 04twoo from Aiffem of scum to b �of o'u-t'l�et I or baffle. low dmsnslons were determined: Canrlsn�M: treeen!rmandetlmi far pumping. 40 inlet end oudet tees a bsfrtes,depth of oviden,oe Mfk4i9e, pick.) Qt e r y �qw Isvel In reletio too at invert. Structural irosoft, ..,.(` .C1L.d f DOM CM eke plan) Depth italp*emle: Motsrkil of aahet uetien„eenarets`metal`Fiberlllass Polyethylene„ol3�er( Wnl Dtmsrrtlons: Scum tNakness: :WW Dieter!afromtollater�unto top Of outlet ( 54w"dOt DMteneo fftm boitarn of scum to bettor"tWtData of fait pwging:freaerlrnsn6rrtlen far prmtpbrug,eondltlon oP toes or betties, depth+ef liquid level in relation tr+outlet invert,atrYCR1rW i evide"ae of tsskaip,st-o.) tour tV, revitietd 9/2/.ili8 Tiese7ofu SUNURFACE AEWAU D1V0$AI iYSTM IN#PECTHM FO11111101 'ART C i TtIM 1100I111111ATHM11 foundg%wdl - Pf�Il•r+ro �..: �/y'S OCR Cf .�� AW orr btopM lien: �$ (oq Car MIT OR H0I.01M TANK: (Tsrik must be pumped prior to, o time of, Inspection) (losrrte on she Owl Depth Mae- f,rada:, mo+s d d of eo mbvc Mn:—eonefste--Mold_,/Mbo sss—Pokysthytons o other(explaln) ®irnees OM,— Caf"h....,...,r._. Design 9low: pallCns/dsY Alarm wasw4.--- Alarm�Isvol:—. Alarm worklino order:Yes� No_ ®alm of provbus PWW0 no: Cormrrosnts: (oCirition of l-det tse ondition of ahem and float switches,ate., 0gt'TIYN6ir7dld f309C:W (Masts on seta OW14 Depth of"Ukl:level above cutlet invert: Conxnrmts. fmale IP Isvel aind dstribution is o!QY�el,ovldsncs of so1ldLL a ryover, vldsnoe of!a again or=ff bCx. eta.) __ � �'Ora �1�3J� (Masts an aft plarii Pungls In weflikV order:(Yes or No),v Alm mx in weVaino cadsr(Yes or No)— Costnrsnts: _,. IrMe aondhlore of pLm*Chamber.CenotatDon s end+sppunanenoes.oft.) reprised 9/2/918 h(yalotll ItUNU11FACE flE WALK DISPO&U$YSTUA NWECTCa1<a FOW PART C SYSTM 013OItISAItd9l1 feerrlfnu" iv",Addhai,�byy9 Lt� ale of +low• �cowl toy soma wAalollNt'IOIA srYs�l aA>el�. (loon*on Me i:aan,if possible; exc stl-3in not repaired, locatlon may be approidmated by non-Intrusive rtwthodcl It rw+i Wonted,;implahv: Typ•: f Washing ph:a.number: lofahing eha nbers,number:__ a owl in*gstlerles,►w"bor:_ loathing bunches,number,WrVh:�,� Washing to",number,drMrelom: ovort:ew ew spwi,nunnber.— A11ar•olve sya»m: �. Nene of Technology. COrnnnefHe: � or, � mote cnnditl4w of sall, sl hydroulla fallure,level of po2djng,demp soM, oiNpidtlon,of vegatstion. etc .�._._...�.o• .ice.. �_�..�.� 110cete on eke iblsn) Num bw•and o rftwatlen- "tepth4ap of N:pM to Inlet Inver: wh of so" Isyer: �eplh r►f scum layw Dinw eslsns of-mapaei: Metrf'lals of ea»f uCtion• Iniftetlon of gt•swftl1watw: 01 I01011?daeaspool nwst be M"d as part of Inspection) Cornmarb: fret,emfrdklor of osA gne of hydrauNc feluro,level of pending,condition of vegetation,etc.) PNVY: 111ocete on of:elan) / D"Ahltot o ea tstruetion: ®Imenslons: ..__._._ Depth r�soMdr. _ Commef : {not,c nbdtlor of sob, f hyslrai le fibure,level of pondrtg, condition of vegetation,etc.) revised 9,/2/98 L a • $UUt FACE IlakWAGE OWFOSAL S1►.S?W W#SPWf10N FORM PART C STSTW 994NMTWN toatatlna om at� k�+ ine wig tips to at low two permanent reference Iw Wn wks or benchnwks IoeaUu all wells within 100'Mccoto winera public water supply ceases into housel i a 12 , �a 1 revised 9/2/98 rep to of it c S 1 t Certified Mail#7006 0810 0000 3524 9674 ,o4WE Towti Town of Barnstable Regulatory Services 13AEtN5TAE3LE, ' 9 MASS. Thomas F. Geiler,Director �prFo��a1� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 20, 2007 Gregory Paul P.O. Box 1055 Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property ,owned by you located at 449 Old Craigville Road Centerville, was inspected on April 10, 2007 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements. Door P Y between kitchen and breezeway not insulated; toilet runs. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by insulating door between kitchen door and breezeway and by fixing toilet so it no longer runs. 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. QAOrder letters\Housing violations\Rental ordinance\449 Old Craipille Road.doc i 4 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 oma A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Timothy O'Connell, Health Inspector Cc: Mary Jane Clergy, Tenant QAOrder letters\Housing violations\Rental ordinance\449 Old Craipille Road.doc Q\_ FORM30 C&W HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BO RDA LTH ` CITY/TOW W CIEPARTMENT ^ADORESS O / GSM svey`aW <� �(J tt l Ll �11 qq TELEPHONE A `t ddress Occupant_- Floor Apartment No. No.of Occu Pants �— No. of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units— _No. ies Name and address of owne �- Remarks Reg. io. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches.- Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: + Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 0 E Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATION CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REP IS SIGNED AND CERTIFIED UNDER E PAINS AND PENALTIES OF PERJU " INSPECTOR r TITLE DATE O TIME A.M. THE NEXT SCHEDULED REINSPECTION � P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety III 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 410.1.00 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 'prohibite-d.by•105 CMR 410..200(B)and 410.202. 4� -h (C) Shutoff and/or failure to restore electricity or-gas. (D)' Failure to provide the electrical facilities required by 105;GMR 4,10.250(B), 410.251(A), 410.253 and the lighting in com- mon area required'by 105 CMR`"4l0.254:. .f a,< (E) Failure to provide a safe supply of.water. i (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. .+_ r ±- � _ (H) Failure to comply with1t t_ - a the security requi, rements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 4,10.600, 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. f (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, asfittin , or electrical wiring standards that do not create an immediate hazard. 9 Y P P 9 9 9 9 9 (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)i-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. 5 T I I s FORM30 Caw HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS e_ 8 OA RD O EALTH r ° CITY/TOWN oJqEPARTMENT l Y (o U AD TRESS O 2�J✓ �f TELEPHONE L1 Ll �/w` ,`�Vy I Address _ Occupant_ Floor T Apartment Na -No.of Occupants—ate_ No. of Habitable Rooms No.Sleeping Rooms No. dwelling or rooming units No.Sto'ries Name and address of own en nrf Remarks Reg. io. YARD Out Bld s.: Fences: ! Garbage and Rubbish i Containers: I Drainage A j Infestation Rats or other: ` " I' STRUCTURE EXT. Steps,Stairs, Porches.- Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Llop, Roof V II Gutters, Drains: ­-7 •`z Walls: Id Foundation: U ► a , Chimney: BASEMENT Gen.Sanitation: Dampness: f Stairs: h J f Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair G TYPE: Stacks, Flues,Vents: PLUMBING: Supply Liner 4 ❑ MS ❑ ST ❑ P Waste Line: i H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters, Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: I Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen „ Bathroom yl0lJ Pantry Den . Living Room 4 Bedroom 1 Bedroom 2 b E Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil.� Vent., Plumb.,Sanit'n.: Wash-Basic� Shower or Tub: Y ;. ' :. _.r fiT - � - ..�_ Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: Q_ General Building Posted Locks on Doors: ONE OR.MORE OF THE VIOLATION 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 i AUTHORIZED INSPECTOR.(See Over) THIS INSPECTION REP RT IS SIGNED AND CERTIFIED UNDER E PAINS AND "FQYy°vv� PENALTIES OF PERJURY ' INSPECTOR TITLE A.M. j DATE - TIME L P 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 II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 4.10.250(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. _ s FORM 30 &w HOBBSB WARREN Tn THE COMMONWEALTH OF MASSACHUSETTS BOARD OFrH,EALTH Cl:TY/TOWN, r J I tf JDEPARTMENT j¢ fi 'o^ ADDRESS G �r TELEPHONE r , f Address L. ''' (�f, � .--�• — Occupant Floor Apartment No. d No. of Occupants___-_ t No.of Habitable Rooms - r No.Sleeping Rooms No.dwelling or rooming units � �No.Stories. Name and address of owner' �a E{ 1 ✓� . 0, z•,,,1 * / w ,Y ��.' Remarks Reg.�1/io. YARD Out Bld s.: Fences: U / Garbage and Rubbish Containers: ' ,c . Drainage S f .., \ i 1 a? "f A•.� .`'w-. Vc`/U _zf Infestation Rats or other: f t Ml � STRUCTURE EXT. Steps,Stairs, Porches: !.-�•. Dual Egress:and Obst'n.: 41- j ❑ B ❑ F ❑ M Doors,Windows: , Roof Gutters, Drains: Walls: r- ,t_. _ . ) " C! t, `'• (> Foundation:Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: STRUCTURE INT. Hall,Stairway: Obst'n.: 1-10 � Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair A TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 11220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: _ Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room r , Bedroom 1 .. i f Bedroom 2 t5 E Bedroom 3 ? •17:- Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil Vent., Plumb.,Sanit'n.: T--' Wash Basih,Shower-or Tub: - - - _ -< - -} . - — ��• : Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKEDABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER -HE PAINS AND PENALTIES OF PERJUFiYI"Y %.441J, � .----` INSPECTOR .." TITLE JJ I z A•M, DATE li'° � . �-' TIME i A.M. THE NEXT SCHEDULED REINSPECTION t at,�' - P.M. t 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. No(F ............. Full( .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH ..........OF...... .., .. .. . Appliratiun -fur Dispugtt1 Works Chun.5trurtiun Vrrniit Application is hereby made for a Permit to Construct ( ) or Repair (t<an Individual Sewage Disposal System at: Loca'on_ r ss or Lot No. . •- --•••---. . .......... ___L.l�..!__`-- wne •� Address ---• -- •-• •-- •••. - mil- �TGDrT Installer Address d ype of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...._.......3__________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity_----------gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No-____________________ Width-------------------- Total Length------------------.. Total leaching area--.-_.-.__--..._____sq. ft. Seepage Pit No------------_------- Diameter-------------------- Depth below inlet.................... Total leaching area..__-_.--._-__..sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------- ----------•------•-•--•---------------•-••--••---•-----._.___----• Date---------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-------.---------....... rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--------------------- ._. --•------------------------------••--------••-•-•--------•-•-- a+' ------------ •-------•-----••---------- O Description of Soil---------._ it::­x U -••-••••---•-••---------------------------- .................................. W x - - - ---- -- - ------------------- U Nature of Repairs or Alterations—Answer when applicable......J.-.�DUQ_ ___. _ .- _ _ ---------------------------------------------- ------------------------------------------------------------J.-J-U-D0._ '•-•"�7� ItGC� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary,; ode—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has 'een)issued by the boar or,.V�7� Si d_._. ------- Date Application Approved By-------- --_-.---•---•--/ --•---•--------•---•••••-••-- ----7-_-- �".7-�:------- Date Application Disapproved for the following reasons:----••---------------------------------------------------•------------------_____-----------•------------------- ---•--.._._..•••.•.•..---•------•-----••--•-••---••-----------•-•-------._.-•-•--•-----•-•-••-•------•---..-•••--•---------•----------------------••---- --••-•-•----------•---------•-••--------------- Date PermitNo......................................................... Issued........................................................ Date (7v r ..f No................ THE COMMONWEALTH OF MASSACHUSETTS BOARD ,OF HEALTH r� Apphratfon -for Bfiipoottl Works Tonfitrurtion Vanift Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: -•----.....•)--...-=--- 1-•C>. IJ.... T...; ....(-.=.. - ---- ---------------------------------------------------------------•--------------------......------- `=��' r r Jjon:_1,0-A ----J1>•_' r//1rfs7 �a :, ---------------------- ----------------- -- Owner Address Or-_ '................................i .........................................r✓Ix �..> ------------- - t_ ................_ rr l ............................ Installer Address Type of Building J Size Lot............................Sq. feet Dwelling—No. of Bedrooms...__......_L............... ...................._--__-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons--______._-.________._______ Showers ( ) — Cafeteria ( ) A. Other fixtures -----------------------------••---•--•--------------------------------_-------- --.........-------•-----._..._...-----.....---.....---•------------ d W Design Flow........................._..................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter__-------...____ Depth---------------- x Disposal Trench—No. ..................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet___________________- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by--------- --------------------_----••---•-•••--•---•--•-----••••--••-•• Date-•-•---------------------------•-_----- ,_l Test Pit No. 1________________minutes per inch Depth of "Pest Pit-.._._____________ Depth to ground water-.._.__-.-.-_-.--.-----. f� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........_---..._____---- -----•-•-------- --------------------------------------------------------------------------------•--•---•-••-----•-••-•-•--------------------------••---- 0 Description of Soil--------------Arl..:..."/__: ..... -------------------------------------- ---------------•---------------------------- U --------------------------------------------------------------------------------------...-••-•--••-••--•-----------•--••••••••-•-------•-••-•-----•...------------------------ ----------------- ----- W x •-------------------- ------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------1_ ,. ------------- ------------------------------ -••-•---------------------------------•--•-•------••------t= i /�l (? /tx l ....._nasT Agreement: J I(V The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of�healtli. ' 1 �i��/ f/' .' G � / f b / f/`- Date Application Approved B Ir �_[6 - ----------------------•---- Date Application Disapproved for the following reasons--------------......--••--•-----••-----•-------•-------•----------•-••--•-----------•-------•---•-•-••••--•----- -------------- Date PermitNo......................................................... Issued----------------------- ................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /...It....-..... .................OF.... _ ................................. .. ...................... Trrtffiratr of f.1ontplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System,constructed ( ) or Repaired �1.+ l Cam,/ f Installer ,r f / �.t at ..__•__.........._____ ___________ _ ______ __ !•J>:•.'_Gt - -_ t/ j1,Ylf ,,rfj .�? .,_ has been installed in accordance With the provisions of Arfi Re XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No/-- '___;L_'?_��........... dated.......7_'__�-- 7C_________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE =------ --------------------------------�----------------..... Inspector------ prz_. s.._...------------------ THE COMMONWEALTH OF MASSACHUSETTS 7G ` BOARD OF HEALTH ......1J� �r1 J ............ hJ � ..-.....of / f' P j No-------------•------•--•- FEE , Bi-tupopal Norkii QTnoitrortiou "rrmit Permission is hereby granted..._______________f---____l_.____`.._._11 !!-f :�t.'_�...1...... ':%'- 1l;'?l ���11� ................. to Construct (4-T or Repair ( )/an Individual Sewage Disposal System attr_1 � -"i'............ /{!,- - l- _, >l . Street as shown on 4thheaplication for Disposal Works Construction ,fieit N.o_.____� _____-___ Dated-__.?_�-.7/.................. DATE 7 Board of X1e51th FORM 255 WARREN. INC.. PUBLISHERS f L I n ° } d431MS UN p7�'CC yam, 40 ,-,�v MA'Y zzi ciF f+ems RO,40 DANIEL ry �� DANIELA. t OlAlra ii 27.7/0 If?,S O 2'� Pa {398(? 1. IL �o w p0 I _ S NOS 39 i N No.46502 14 / �Els�RO _I_ a °� � pia OCu Q / l F st�� ` is m , T �1 Q0�26.07 ! L3.81� ' >>D AQ k �0S r��;i�4 ` Q yJ�-1 y x 30.51 S 31.28 �h Rd. MAP 247 PCi_ 37 I P.L.S. rat ;Ile 82 ti h � DATE DANIEL A. OJALA, P.E., 14,592t SO OR 0.33 AC CONTINUE USE OF / EXISTING THREE / CONC. f BEDROOM SEPTIC PAD \ a SY .� 32,38 PROPOSED SEPTIC PIPE 2&.7 t � x 28.50 � -+(3+.2a O �. SLOPE 2� O I INVERT 29.0±0 TANK I 3 \ O xx 32.Oe { EXISTING 25(68 S "3' � �. (W.F.) 11 � � ' I , / 26.33 1 ry o; r, f/? � � 3'd.&2 x.� 'po 'r �ti `lr °�o�° ZONING SUMMARY LOCUS MAP i 22" TREE °� i 54>' p t? 32.i 4 G�A� SCALE 1"=2000't I 1� 4 'Q ZONING DISTRICT: RB c ASSESSORS MAP 247 PARCEL. 37 t } x 29 is x 3i.0a `3 -- MIN. LOT SIZE 43,560 S.F. � 0 � `;�}� � ��`- ',�✓,,� 1��0 LOT AREA: 14,592t SF r MIN. LOT FRONTAGE 20 LOCUS IS WITHIN FEMA FLOOD ZONE C �°9 MIN. LOT WIDTH 100, DATUM: APPROX. NGVD s`r x 28.4b tI Oo.'" O MIN. FRONT SETBACK 20' ARK: 31.67 MIN. SIDE SETBACK 10* REFERENCES PROPOSED a BENCHM MIN. REAR SETBACK 10� .,` \ s Ji,67 SITE IS LOCATED WITHIN AP DISTRICT DEED BOOK 15921 PAGE 231 THREE BEDROOM <, �„� cy4'� i DWELLING ' ,y� w w w } SITE IS NOT WITHIN RPOD PLAN BOOK 76 PAGE 1 449 OLD CRAIGVILLE,ROAD ,y1• ;7e9- 31.05 i 30.39 SEPTIC SYSTEM AS-BUILT PER = I p T.O.F.=32.6 / - _ SITE IS NOT LOCATED WITHIN INSPECTION REPORT i 0 90 `'S�`' / '' �, NHESP JURISDICTION x : 30.77 ` 1� 1 "x . �. 9 29.36 \ 30.89 32 240-91 H �. o r-3 -.� 0.5;> \ \ •a 3i tip, �j 1. LOT CONTAINS OVER 10,000 SF \ \ O\x a �' `' a 60 \ �_ a, PROPOSED HOUSE CONFORMS TO CURRENT ZONING. SETBACKS. �os7 �` 0a. b.1. PROPOSED LOT COVERAGE BY BUILDINGS AND STRUCTURES IS 10.1$ (f10� =OK). \ \ \ 29 97 d b.2. PROPOSED FLOOR AREA RATIO IS 0.178 (G0.30 IS OK). b.3. PROPOSED HOUSE DOES NOT EXCEED 30' AND IS ONE STORY (OK). \ ,�ti \ PROPOSED DWELLING I 29.2, 29.29 NOTE: SITE PLAN 29.05 , CONTRACTOR SHALL BE OF RESPONSIBLE FOR CALLING i \ 2�6$ � DIGSAFE (,-sLi8-344-7233) 449 OLD CRAIG�/ILLE RD. 2�70 op\ AND VERIFYING THE LOCATION W. HYANNISPORT OF ALL UNDERGROUND do Off 508-362-45t1 OVERHEAD UTILITIES PRIOR O I fox W8-362-988o p COMMENCEMENT OF WORK. downcope.com o 28.1 I PREPARED FOR doWO C4pe en ineerin ,Inc, a.! c�% engineers SCgie:1»= 20' GEORGE DAVIS BLDRS.. land surveyors i 939 Main Street Rfe sA) SEPTEMBER 27, 2010 YARMOUTHPORT MA 02675 0 10 20 30 40 50 FEET 09-297 1 i t