HomeMy WebLinkAbout0322 OLD STAGE ROAD - Health 322 Old Stage Road
`�- Centerville, MA
A = 190 - 106
UPC 12534
o.2-
` Commonwealth of Massachusetts .
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
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 forms A. General Information
on the computer,
use only the tab 1. Inspector. - -
key to move your n /j�✓j�
cursor-do not Matthew Gilfoy `J\ (j/� I/
use the return key. Name of Inspector
B&B Excavation, Inc.
Q Company Name
14 Teaberry Lane
Company Address.
Forestdale . MA 02644
Cityrrown State Zip Code
(508)477-0653 S113640
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Full'
".k) ,: e-,),
El Needs Further Evaluation by the Local Approving Authority
(JI
1-30-14 ,,33
Inspec r'tos ignature Date
The stem 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
1 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer,.if applicable, and the.approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how.the system will perform in the future under
the ame or different conditions of use.
I
t5ins•3113: Title 5 Official Inspec. n rem: Sewage Disposal System•Page 1 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M a' 322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® 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 Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is
required for every Centerville Ma 02632 1-31-14
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.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
_ W Title 5 Official Inspection _Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town - State Zip Code - Date of Inspection -C. Checklist -
Check if.the following have been done..You must indicate":yes" or"no as to each of the following:
Yes No
El ® 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?
0 ❑ Were as built plans of the system:obtained and examined?(If they were not
available note as N/A):
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design):, 3 Number of bedrooms (actual): 2
DESIGN flow based.on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 330
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17
...
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 1 year ago
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Tifle 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
322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. Cityrrown 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•3/13 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
322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1988 COC
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1 8
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appears to be in good working order with no signs of leakage.
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallon
Sludge depth:
3'
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. Cityrrown 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
29"
Scum thickness
0'
Distance from top of scum to top of outlet tee or baffle NS
Distance from bottom of scum to bottom of outlet tee or baffle NS
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 tank appeared to be in good working order with no evidence of leakage. Tank
does not need to be pumped at this time. Tees in place
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
0"
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 appeared to be in good condition with no evidence of carryover or
leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-6'X6'
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appeared to be in working condition with no sign of hydraulic failure. Pit
was dry at time of inspection with a high stain line 1'8" below invert.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owners Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A �
O O
A I- 2-y'
A2- ZZ.'
xj q 3
3
• `6 � I s'
2- y'
b3. 30
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >10'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database -explain:
qw greater than 10' per USGS topo map
You must describe how you established the high ground water elevation:
topo map plus previous inspection report on file at BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 322 Old Stage Rd.
Property Address
Vincent Janollari
Owner Owner's Name
information is required for every Centerville Ma 02632 1-31-14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
!. L
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
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: A. General Information -
When filling out '.. 4 C p
forms on the
computer,use 1. Inspector:
only the tab key a
to move your Robert Paolini :.Q
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC. - 7
Company Name
P.O.Box 763
Company Address ,y
Centerville Ma. 02632
reran City/Town State Zip Code
(508)477-8877 S14454
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
4/20/2011 i
Inspector's tgnature Date t
r'
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 systep 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 Towner
and copies sent to the buyer, if applicable,,and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Ud-
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage isposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
^M 322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® 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 1/2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every 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 11 of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
El Was the facility owner(and occupants if different from owner) provided with
® information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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 2010:46,000
g ( y g (gp ))' 2010:46,000'
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 4/20/2011
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
,M 322A Old Stage Rd.
.Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. CitylTown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
S
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every 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:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 1811
felt
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
Depth below grade: 1
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: 1000 gallon
Sludge depth:
3"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
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.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. Cityfrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Water level was 2' below invert with no stain line higher.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Map Page 1 of 2
Town of Barnstable Geographic Information System
Parcel Viewer Custom Map Abutters Map Size Zoom Out fl I fl i fi l®In
i 3
:i
0 .
f
i- '.
Set Scale 1" 20 I Aerial Photos I MAP DISCLAIMER
- ....
(:nrnirinh}9MGAMn Tnwn nt P.—tohlc AAA All rinhte roecnn
hrtn•//66 q.n,3 95 ?.,16/arcim./,qnngenann/man.asDx?DroDertvID=190106&manparback=l901... 4/26/2011
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
-
every page. Cityfrown 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: Bottom of LP 20'
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:
As-Built
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
�M 322A Old Stage Rd.
Property Address
Ellen Clemence
Owner Owner's Name
information is required for Centerville Ma. 02632 4/20/2011
every 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r
.� CERTIFIED MAIL, ; .
'H�E'Ojy Town of Barnstable
i! P
Public Health DivisionRARNST r � `
AU`F a 200 Main Street gb °j� `em
Hyannis, MA 02601
7003 1680 0004 5458 , 2_
�-FfT�gwFo
RETURN RECEIPT =Er4oEA
REQUESTED ee S-/re e- ❑ MOVED,I FFl NO ADDRESS
O oT DEI IVERAB!E AS
of, / UNABLE TO FORWARD I
• 0 p'/ 0 TTFMPIED NOl Kplol
00 UNCIAIMED f-
j RF,iI2gd KDOM
NO SUCH STRFET hUI
❑ DO NOT REMA!! IN TiiIS EPaVLLUPE
❑ INSUI IICIENI ADDRESS
U✓ ^❑ NO MAIL P,ECfrT,gj
!! jj EE �i. • .:i1rt.'4'� _. 9"�! {_x Is j.
i1lTi!':f.l tE114.911-....._..d`1.1.:1:tP .�-,3:- it.tit.I:t l:�.it3i1i:E-atf illf7
!
II
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
I item 4 if Restricted Delivery is desired. ❑Agent
I ■ Print your name and address on the reverse ❑Addressee
I so that we can return the card to you.■ Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date of Delivery
I or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
I I
I I
0 Greevl 5f re ej
3. Service Type
I A �� w��� Certified Mail ❑Express Mail
0 f ❑ Registered ®Return Receipt for Merchandise
I ❑ Insured Mail ❑C.O.D.
I 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number 7 I1 R 7 \
a -1680 0004 5458 2216
Receipt 102595-02-M-1540
Certified Mail#7003 1680 0004 5458 2216
o � Town of Barnstable
~ Regulatory Services
s,,xrtsrnHt Thomas F. Geiler, Director
Mnss.
r 26194 Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
June 3, 2005
Ellen Clemence "
86 Green Street
Norwell, MA 02061
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II
- MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND
VIOLATIONS OF THE TOWN OF BARNSTABLE CODE.
The property owned by you located at 322 Old Stage Road, Centerville,MA-was inspected-on',
June 2, 2005 by David Stanton>R:S.; Health Inspector for the Town of Barnstable, because of a
complaint.
The following violations of the State Sanitary Code were observed:
105 CMR 410.351(A): Owner's Installation and Maintenance Responsibilities: The stove
was observed missing one of the control knobs.
105 CMR 410.351(A): Owner's Installation and Maintenance Responsibilities: The heating
system was observed inoperable.
105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: Paint was
observed flaking off the ceiling.
105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: The front
cement stairs were observed caved in.
105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: The wood
railing on the deck was observed broken and was.very loose.
'1055 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: A large
-rotting hole was observed in the soffit. 1 p,
105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: W basement
window was observed missing.
Q:Order letters\Housing violations\322 Old Stage Road.doe
105 CMR 410.550(A): Extermination of Insects, Rodents and Skunks: Evidence of rodents
observed, including several pieces of rodent feces. Several defects in the structural elements
allowed for the entry of rodents.
The following violation of the Town of Barnstable Code was observed:
Town of Barnstable Code �170-7: Owner's name, address and telephone number were not
posted outside.
Town of Barnstable Code §170-7 reads as follows:
An owner of a dwelling which is rented for residential use, who does not reside therein and who
does not employ a manager or agent for such dwelling who resides therein, shall post and
maintain or cause to be posted and maintained on the exterior of such dwelling within five
(5) feet of the main entrance or within five (5) feet of the mailbox(es), at least four(4) feet and
not greater than six (6) feet above ground level, a notice constructed of durable material, not less
than twenty square inches in size, bearing his/her correct name, address and telephone number. If
the owner is a realty trust or partnership,the name, address, and telephone number of the
managing trustee or partner shall be posted. If the owner is a corporation,the name, address, and
telephone number of the president of the corporation shall be posted. Where the owner employs a
manager or agent who does not reside in such dwelling, such manager or agent's name, address,
and telephone number shall also be included in the notice.
You are directed to correct the violations listed above within Thirty (30) days of your
receipt of this notice by replacing the missing stove control knob, repairing the heating
system, remove the flaking paint on the ceiling and painting over those areas with new
paint, repairing the front stairs, repairing the broken deck railing, replacing the rotted out
soffit, replacing the basement window, exterminating the rodent infestation, and by posting
the building properly per the Town of Barnstable Code §170-7.
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.
PER ORDER OF THE BOARD OF HEALTH
40om�as�A. McKean, R.S.
Director of Public Health
Town of Barnstable
Q:Order Ietters\Housing violationsl322 Old Stage Road.doc
Postal
(DomesticCERTIFIED MAIL REC�JPT
ru Only;
RJ
For delivery information visit our welbsite at www.usps.coma
cc T
artrx US
Ln Postage $ . 37 `S M,1 O
Certified Fee 2 3(2 /�i\� 2�0
p Postmark
� ( Return R qpt Fe; '7 , 1��_�e�OC
Endorsement Re cared < / ✓ J J
C3 Restricted Delivery Fee
CO (Endorsement Required)
-a L� G�
'� Total Postage&Fees $ / r.2 LISPS
o Sent To F Iles CIPmepine
N Street,Apt M;------
-----------------
- ----
or PO Box No. �j{r 2 2
ary,stare,ZIP+4
------------- ..............................
AL
MA 2
PS Form :10 June 2002See Reverse for Instructions
Certified Mail Provides: (as�anay)Zppzeun( 008£ d Sd
■ A mailing receipt
■ A unique identt ier for ypeur mailpiece
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
■ Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE'COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted-Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
Internet access to delivery information is not available on mail
addressed to APOs and FPOs.
Certified Mail#7003 1680 0004 5458 2216
MaY� Town of Barnstable
Regulatory Services
w RARNSTABLL Thomas F. Geiler, Director
ernes.
Fo5 °i'�� Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
June 3, 2005
Ellen Clemence
86 Green Street
Norwell, MA 02061
NOTICE TO ABATE VIOLATI.ONS OF 105 CMR 410.000, STATE SANITARY CODE II
- MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND
VIOLATIONS OF THE TOWN OF BARNSTABLE CODE.
The property owned by you located at 322 Old Stage Road, Centerville, MA was inspected on
June 2, 2005 by David Stanton R.S., Health Inspector for the Town of Barnstable, because of a
complaint.
The following violations of the State Sanitary Code were observed:
105 CMR 410.351(A): Owner's Installation and Maintenance Responsibilities: The stove
was observed missing one of the control knobs.
105 CMR 410.351(A): Owner's Installation and Maintenance Responsibilities: The heating
system was observed inoperable.
105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: Paint was
observed flaking off the ceiling.
105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: The front
P tY
cement stairs were observed caved in.
105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: The wood
railing on the deck was observed broken and was very loose.
105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: A large
rotting hole was observed in the soffit.
105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: A basement
window was observed missing.
Q:Order Ietters\Housing violationsl322 Old Stage Road.doc
105 CMR 410.550(A): Extermination of Insects;Rodents and Skunks: Evidence of rodents
observed, including several pieces of rodent feces. Several defects in the structural elements
allowed for the entry of rodents.
The following violation of the Town of Barnstable Code was observed:
Town of Barnstable Code 4170-7: Owner's name, address and telephone number were not
posted outside.
Town of Barnstable Code §170-7 reads as follows:
An owner of a dwelling which is rented for residential use, who does not reside therein and who
does not employ a manager or agent for such dwelling who resides therein, shall post and
maintain or cause to be posted and maintained on the exterior of such dwelling within five
(5) feet of the main entrance or within five (5) feet of the mailbox(es), at least four(4) feet and
not greater than six (6) feet above ground level, a notice constructed of durable material, not less
than twenty square inches in size, bearing his/her correct name, address and telephone number. If
the owner is a realty trust or partnership,the name, address, and telephone number of the
managing trustee or partner shall be posted. If the owner is a corporation,the name, address, and
telephone number of the president of the corporation shall be posted. Where the owner employs a
manager or agent who does not reside in such dwelling, such manager or agent's name, address,
and telephone number shall also be included in the notice.
You are directed to correct the violations listed above within Thirty (30) days of your
receipt of this notice by replacing the missing stove control knob, repairing the heating
system, remove the flaking paint on the ceiling and painting over those areas with new
paint, repairing the front stairs, repairing the broken deck railing, replacing the rotted out
soffit, replacing the basement window, exterminating the rodent infestation, and by posting
the building properly per the Town of Barnstable Code §170-7.
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.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S.
Director of Public Health
Town of Barnstable
Q:Order letters\Housing violations\322 Old Stage Road.doc
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HAB ATION
Datetb-kc- C
Owner �l.P_✓!(. (^� 3�1 Q- Tenant WA,.,c
Address Address iz2t yl �.(� u C-V
Compliance Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities Lx S `'� `0I°� i"Im y/0,
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities V g(I,o, - rf&)
7. Lighting and Electrical Facilities
Q. Ventilation
I
9. Installation and Maintenance of FacilitiesA2 LA
��
10. Curtailment of Service
11. Space and Use , 90
12. Exits t✓t Ckt ��
13. Installation and Maintenance of Structural S h
cl�E4ements w` ( One ov
14. Insects and Rodents ��R'� fib-��� � P��� if
15. Garbage and Rubbish Storage and Disposal wow
16. Sewage Disposal V10, f✓ *d, }-5V
17. Temporary Housing
PART II
0
37. Placardirig of Condemned Dwelling; I p v
Removal of Occupants; Demolition
Person(s)Interviewed Y, Inspectors
If Public Building such as Store or Hotel/Motel specify here
Barnstable Assessing Search Results Page 1 of 2
r� u
ms
Home: Departments.Assessors Division: property Assessment Search Results
322 OLD STAGE ROAD
Owner:
SCHUMACHER, ELLEN M Property Sketch Legend
Map/Parcel/Parcel Extension
190 /106/
Mailing Address
SCHUMACHER, ELLEN M ,& 3
%CLEMENCE, ELLEN SCHUMACHER
� 3 3
86 GREEN STREET
NORWELL, MA. 02061
f
2005 Assessed Values:
Appraised Value Assessed Value
Building Value: $85,800 $85,800
Extra Features: $0 $0
Outbuildings: $0 $0
Land Value: $ 127,800 $ 127,800 Interactive Property Map: ap requires Plug in:
Totals:$213,600 $213,600 1 have visited the maps before ?'
Show Me The Mao
April 2001 photos available _
Sales History:
Owner: Sale Date Book/Page: Sale Price:
SCHUMACHER, ELLEN M 2733/135 $0
2005 REAL ESTATE Tax Information: Tax Rates: (per$1,000 of valuation)
Land Bank Tax $38.77 Town Fire District Rates Other I
$6.05 Barnstable-Residential $2.12 Land B•
Barnstable-Commercial $2.80
C.O.M.M. FD Tax(Residential) $215.74 C.O.M.M.-All Classes $1.01
Cotuit FD-All Classes $1.28
Town Tax(Residential) $ 1,292.28 Hyannis-Residential $1.52
Hyannis-Commercial $2.39
W Barnstable-Residential $1.44
W Barnstable-Commercial $2.10
Total: $ 1,546.79 Due to rounding differences these values may vary
http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/... 6/2/2005
Barnstable Assessing Search Results Page 2 of 2
Land and Building Information
Land Building
Lot Size(Acres) 0.58 Year Built 1979
Appraised Value $ 127,800 Living Area 795
Assessed Value $ 127,800 Replacement Cost$98,662
Depreciation 13
Building Value 85,800
Construction Details
Style Ranch Interior Floors Carpet
Model Residential Interior Walls Drywall
Grade Average Heat Fuel Gas
Stories 1 Story Heat Type Hot Air
Exterior Walls Wood Shingle AC Type None
Roof Structure Gable/Hip Bedrooms 1 Bedroom
Roof Cover Asph/F GIs/Cmp Bathrooms 1 Bathroom
Total Rooms 3 Rooms
Extra Building Features
Code Description Units/SQ ft Appraised Value Assessed Value
Property Sketch Legend
BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished)
BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished)
FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished)
FCP Carport GRN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
FOP Open or Screened in Porch TQS Three Quarters Story(Finished)
http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/... 6/2/2005
r-
,. .. _. � � •"�- �. ., .:.. `key^-5�Ylri'
AM
,�',:;
d Stage Road, Centerville. IDS
4.
1 , 1
r
yYl. rr, f
i
AW
r _ .�� •
Mr
Mya -
1-
iL
J -
t
wpm
4 \
VZZ
ell
Oil?
+ JA
✓ t,
r .,.
y
32 Old Stage R d, Cente ille. IDS .t
ij
Ilk
1
I
r rN
a ,h�
M1.
ram{ -
�- tr _
s.
1
' •` `�- �� !� - tom' + -
�, -� r - �..:, z +d?-, •""fir' ..�-.. i',
-y"�'-`ti^ vii.' "`"1.t='�'.' ter'•_ w '� 'F- 'L_..,.° �-
I,
��
`�
w
.�
�il�' -
�:, i
4��
i �_ �,
i
i
b,
,::n '
'� � �'
-,.:
��
• 3 �.
• •
� �3: • '
�� � •
�j� �
' '* ` v
�..
- f
tit �
tip
�, .g(,,,}"�r- �, � � r'.:': 1'.. '?sue r'•� h.�[r�? ,�'� �.
S
�- to
�t ky Y•* •� yl
�.
• •
}
R .
U
F F 4
aka a.
G -
h
r
f
r„
Health Complaints
27-Mar-06
Time: 12:05:00 PM Date: 6/1/2005 Complaint Number: 18141
Referred To: DAVID STANTON Taken By: JUDITH FLYNN
Complaint Type: CHAPTER II HOUSING
Article X Detail: UNSANITARY CONDITIONS
Business Name:
Number: 322 Street: OLD STAGE RD
Village: CENTERVILLE Assessors Map_Parcel:
Complaint Description: CALLER STATES THAT HOUSE IS
INFESTED WITH MICE- RACOONS UNDER
HOUSE-STEPS AT FRONT DOOR ARE
BROKEN - RAILING NOT SECURE.
ALTHOUGH WINDOWS WERE WORKED ON
NAILS WERE LEFT EXPOSED INSIDE AND
OUTSIDE. APARTMENT WAS FILTHY WHEN
CLLER MOVED IN -WATER HEATER LEKED
WATER ALL OVER CLOTHS AND OTHER
BELONGINGS-CALLER TOOK IT UPON
HIMSELF TO REMOVE HEATER AND BRING
IN AND PAY FOR NEW UNIT. LANDLADY
HAS ASKED (EVICTED) CALLER TO LEAVE.
CALLER ASKED THAT YOU PLEASE CALL
SO THAT HE CAN BE THERE TO LET YOU
IN - TELE#508-360-5386. IF NO ANSWER
PLEASE LEAVE NOT AND NUMBER SO
THAT HE CAN GET BACK TO YOU.
Actions Taken/Results: DS WENT TO SAID LOCATION. NO ONE
HOME. DS CALLED NUMBER IN
COMPLAINT, LEFT MESSAGE ON JESSICAS
VOICE MAIL. DS GOT A HOLD OF MARK ON
THE OTHER PHONE NUMBER LISTED, AND
I
SCHEDULED TO MEET AT 3:00 PM. DS MET
1
Health Complaints
27-Mar-06
MARK AT 3:00 PM AND CONDUCTED AN
INSPECTION. INSPECTION REPORT ON
FILE WITH VIOLATIONS, AND ORDER
LETTER WILL BE MAILED WHEN DS GETS
TIME TO WRITE IT UP. ORDER LETTER
MAILED. CAME BACK UNCLAIMED. HAVE
NOT HEARD BACK FROM TENANT OR
LANDLORD.
Investigation Date: 6/2/2005 Investigation Time: 11:30:00 AM
2
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE 11:MINIMUM STANDARDS FOR HUMAN,HA ATION
n
Date C !� '
Owner ]/P.� r l?6,f I Tenant �,6,r 1 p r rc,4
1
Address eA Address 2� V C�" C V
Compliance Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities `'e h A �(f f,
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities i/
6. Heating Facilities v, / (bi(,^ h r.
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
i�
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements �, (SireI,
14. Insects and Rodents / ('uctitYl fib. �ir� /�C�Se� —One
15. Garbage and Rubbish Storage and Disposal ✓ `r40w��G./E'r
16. Sewage Disposal L
17. Temporary Housing /� J
PART II
37. Placarding of Condemned Dwelling; v
Removal of Occupants; Demolition /U-
Person(s) Interviewed Ak Inspector
If Public Building such as Store or Hotel/Motel specify here
Ah
Health Complaints
16-Jun-05
Time: 12:05:00 PM Date: 6/1/2005 Complaint Number: 18141
Referred To: DAVID STANTON Taken By: JUDITH FLYNN
Complaint Type: CHAPTER II HOUSING
Article X Detail: UNSANITARY CONDITIONS
Business Name:
Number: 322 Street: OLD STAGE RD
Village: CENTERVILLE Assessors Map_Parcel:
Complaint Description: CALLER STATES THAT HOUSE IS
INFESTED WITH MICE- RACOONS UNDER
HOUSE-STEPS AT FRONT DOOR ARE
BROKEN - RAILING NOT SECURE.
ALTHOUGH WINDOWS WERE WORKED ON
NAILS WERE LEFT EXPOSED INSIDE AND
OUTSIDE. APARTMENT WAS FILTHY
WHEN CLLER MOVED IN -WATER HEATER
LEKED WATER ALL OVER CLOTHS AND
OTHER BELONGINGS - CALLER TOOK IT
UPON HIMSELF TO REMOVE HEATER AND
BRING IN AND PAY FOR NEW UNIT.
LANDLADY HAS ASKED (EVICTED)CALLER
TO LEAVE. CALLER ASKED THAT YOU
PLEASE CALL SO THAT HE CAN BE THERE
TO LET YOU IN - TELE#508-360-5386. IF
NO ANSWER PLEASE LEAVE NOT AND
NUMBER SO THAT HE CAN GET BACK TO
YOU.
Actions Taken/Results: DS WENT TO SAID LOCATION. NO ONE
HOME. DS CALLED NUMBER IN
COMPLAINT, LEFT MESSAGE ON JESSICAS
VOICE MAIL. DS GOT A HOLD OF MARK ON
THE OTHER PHONE NUMBER LISTED,AND
1
w
Health Complaints
16-Jun-05
SCHEDULED TO MEET AT 3:00 PM. DS MET
MARK AT 3:00 PM AND CONDUCTED AN
INSPECTION. INSPECTION REPORT ON
FILE WITH VIOLATIONS, AND ORDER
LETTER WILL BE MAILED WHEN DS GETS
TIME TO WRITE IT UP.
Investigation Date: 6/2/2005 Investigation Time: 11:30:00 AM
2
i3oara oT meaun
Town of Barnstable r _��►
F .O. Box 534
"y7 FI anrds, Massachusetts 02601
No..
-_... .. Fimim ..A o ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
avertOF.... 4f11a 91a-.........................................................
Appliration for lliipaaaal Works Tnnitrnrtiun rrntit
Application is hereby made for a Permit to Construct ( ) or Repair (4() an Individual Sewage Disposal
System at:
....� z.A ----------------
ocation-Address oy.Iot I�
Z Ir4h...S Y.*+ ar-..Clamer ce,----•.................. .19A--QW-S o u...1 4n srij�e_...
Owner Add
ress
a / ..._ecs�n0Q60 ._ i.h..5•_[ �'�_. ±�k _�l4r�ut
-----------------------------------------
Installer Address
Type of Building Size Lot............................Sq. feet
U DwellingNo. of Bedrooms............................................Ex ansion Attic— p ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QOther 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--------------_--------
f-IL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W ----•-----•.....................•-••--•--•-•-•--••---•-•-...---••-•••••••••-----........--•-•••--.......-••••-•...------------••-••-....--••••......--•••----
0 Description of Soil........................................................................................................................................................................
x
V •-----------•--•-------•--•--•---•---•••...••---••-•--•......---•-----•---•-••---•-•-•-------•--•----•-•-------••-•---•-------••••----•-•-----•--------•-----•-•--•---•-----•---••-------•------------
W
U Nature of Repairs or Alteration Answer when applicable. nels4kY...- .G�OCr,(__�,fIS��TGetaG�-_jGOQ g�____
s. r > �xara... ---------------------------------------------------------- ---------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TA!':IZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed e�K�2da..............................-... ... -1?
Date
Application Approved By.............. _().. ......
Date
Application Disapproved for the following reasons-------------------------------------•-------------------------------------------------------------------_•-•---
--•--•--•-•-------•-•-•..............•---•••----•••••-----•••-•---••-•-•-•••--•••-•-----•-...•-•••---••------••.••••-•••••-•-•-•--••-----••--------•-----•-•-•-•--....................................
Date
Permit No........ .16' .-Y.20---------------------•. Issued.......................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
No..�409-Y20. Fim...............::............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... 1... ......................OF..............................,..............................................................
ApVfiraffon for Digpaaal Works TunBIrurtion muff
Application is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal
System at:
zz ^.
• --------•-•-•-• ............................................................... ..---••---......---------....-•-•-----...--•-.........---•----•.._..----•---•--------•--•---------
1 Location-Address or Lot No.
...................-...........-......
Owner _ Address
W t i t
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q1 Other fixtures .................................. ......
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit............_....... Depth to ground water--_-_--_-----___--___...
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----.---__---__----__--
----•----------------------------------------------•------------•------••----------------.----•-.........................................................
0 Description of Soil........................................................................................................................................................................
W ------------------------------------------------------------------------------------------------------•-------------------------------------...---•--------•------------------•----------•-------------
UNature of Repairs or Alterations—Answer when applicable_ _--- _----_ . _ 1_____. �.__._c__!�.._._..
I
•...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITS y g g p y
5 of the State Sanitary Code—The undersigned further reel not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed............... + �r r 1 _
-------------------------•-••-------•---•---•----•--•-. ----------------................
p Date
Application Approved By................ �`-•""... -1^�-`——� ..... ..'.�S__-.4.sF'..--•---
�/ Date
Application Disapproved for the following reasons---------------••------•-----------•--------------------•-----------------------••--------------------.......•---
................•----•••-----•-•----•--•-••--•-.......---......----•----------•-------•-•---------•..._....•---•-........---------------••--••--------•---------•---------------------•--------.......---
Date
6 -y_7_Permit No....... -- - ........................ Issued_.......................................................
Date
� r �
THE COMMONWEALTH OF MASSACHUSETTS
' BOARD OF HEALTH
.........................................OF..?............!...... :...........................................................
�rrtifiratr of �rr�t�rli��cr�e
THIS IS TQ CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ,' )
by..................... ----� .?.....C-....:.'.....................------.....-------------•----------------•--•----•-•---•-----•---------....---------.....--------•----•-----•---------•--
/ — Instablet1 n�j
at-------------•-. �" ...---...elzck._._..5 _'f_�?� (...--•--••---•-------------..._.....-•---------------
has been installed in accordance with the provis of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......... 8.....V.�.O....... dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
r� THE COMMONWEALTH OF MASSACHUSETTS
'.1-' BOARD OF HEALTH
( � - 7 7o ...........................................OF......................................................................................
1V 0.--•.................... FEE........=...........
t t�i Fti FU Pp #rurfion Prlttt
Permission is hereby granted..................'--,i.�_................`r- -......----------------•------------.............---•--.....------•---...----•---
to Construct ) or Repai ( ) an Individual Sewag. Disposal System hoat No--------------� .....�..._�._....S_�t � - � � `` At�'
Street
as shown on the application for Disposal Works Construction Permit No_'__`../..�1 Dated..........................................
........................................... ---.....................................................
Board of Health
DATE................ ......./5---------�
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS "
TOWN OF BARNSTABLE
LOCATION 4 0 SEWAGE # e�`�- LI -70 _
VILLAGE ASSESSOR'S MAP 6i LOT
INSTALLER'S NAME PHONE NO. A & B CANC'O 775-6264
SEPTIC TANK CAPACITY 1066
LEACHING FACILITY:(type) (/boo (size)
NO. OF BEDROOMS PRIVATE WELL OR BLIC ATER
BUILDER OR OWNER ( ' ,ongP l'2(e
DATE PERMIT ISSUED: '
T
DATE COMPLIANCE ISSUED: SC L -5 -
VARIANCE GRANTED: Yes No L/
. � ��� /-r
i
t
��
fi
a
F