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HomeMy WebLinkAbout0098 PARK AVENUE - Health 98 Park Ave. (Centerville) A= SENDER:COMPLETE THIS SECTION COMPL�ETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3. A. Sig ature • Print your name and address on the reverse X Agent so that we can return the card to you. El Addressee ■ Attach this card to the back of the rnailpiece, B. R eiv by(Printed Name) C. Date of Deliv]ery or on the front if space permits: �> v 2,7,4 1.-Article Addressed_to:: _ D. Is livery address different from item 17 O Yes If ES,enter delivery address below: ❑No Sean Fitzgerald 98 Park Avenue Centerville, MA 02632 II I'lll'I IIII III I I I I I I II I�I�III I I�II II'I II I II I 3. Service Type ❑Priority Mail Express ❑Adult Signature ❑Registered MaiITM ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted ❑Certified Mail® Delivery 9590 9403 0922 5223 8276 49 ❑Certified Mail Restricted Delivery ❑Return Receipt for -❑Collect on Delivery Merchandise 7 Collect on Delivery Restricted Delivery ❑Signature Confirmation*M ?7 014 1200 0 0 01 0 3 5 8 W 18 3 7 Insured Mail ❑Signature Confirmation insured Mail Restricted Delivery Restricted Delivery. (over$500) PS Form 3811,July'2015 PSN 7530-02-000-9053 to Domestic Return Receipt USI?S T AGKti[ C{ :; First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 94�3 2" 23 8276 49 United States 'Sender:Please print your name,address,and ZIP+4®in this box* Postal Serv° -- - R Town of Barnstable Health Division, I 200 Main Street I 'i'I'ihit Jill,,Il,,+;i'!Jill `1iiIIIIi,IIiii Jill ili1MI i Certified Mai14 7014 1200 0001 0358 4183 �I Ta Town of Barnstable o� Regulatory Services * BARNSPABM ' MASS g Richard Scali,Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 21, 2016 Sean Fitzgerald 98 Park Avenue Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.0,00, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION,. The property owned by you located at 98 Park Avenue, Centerville, MA was inspected on July 20, 2016 by Timothy O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint received at the Health Division. The following violations of the State Sanitary Code were observed: 105 CMR 410.450—Means of Egress. A room was observed being used as a bedroom within an out structure on this property without proper second means of egress as required by 780 CMR 3603.10.4.1of the Mass State Building Code. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by ceasing the use of said room within this structure as a bedroom and removing any sleeping material. 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 E BOARD OF HEALTH T omas A. McKean, R.S., HO Director of Public Health Town of Barnstable Q rder letters\Housing violationsTental ordinance\98 park ave 7-21-16 Health Master Detail Page 1 of 1 Logged In As: TOWN\oconnelt Health Master Detail Wednesday,July 20 2016 ADplication Center Parcel Lookup Selection Items Parcel Septic Perc Well Fuel Tank Parcel: 208-135 Location: 98 PARK AVENUE, Centerville Owner: FITZGERALD, SEAN M &]ONES, SANDRA L TRS Business name: Business phone: Rental property: ❑ Deed restricted: ❑ Number of bedrooms : 0 Contaminant released: ❑ Fuel storage tank permit: ❑ R Save 77 Parcel Changes Return to Lookup Parcel Info Parcel ID: 208-135 Developer lot:LOT 14 Location:98 PARK AVENUE Primary frontage:115 Secondary road:LINDEN AVENUE Secondary frontage: 105 Village:Centerville Fire district:C-O-MM Town sewer exists at this address:No Road index:1204 Asbuilt Septic Scan: 208135_1 Interactive map Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT Owner Info Owner: TRS FITZGERALD, SEAN M &JONES, SANDRA L Co-Owner:j & F REALTY TRUST Street1:98 PARK AVENUE Street2: City:CENTERVILLE State:MA zip: 02632 Country: Deed date:6/16/2009 Deed reference:23807/344 Land Info Acres: 0.27 use: Single Fam MDL-01 zoning:RD-1 Neighborhood: 0109 Topography:Level Road:Paved Utilities:Public Water,Gas,Septic Location: Construction Info[Building N Year BuiltiGross ArealLiving Are Bedrooms Bathrooms 1 11930 13384 11715 14Bedroorn 2FJ-0 Half Buildings value:$123,600.00 Extra features: $28,800.00 Land value: $245,500.00 http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=208135 7/20/2016 Citizen Web Request Page 1 of 3 rX w. y+ 13 Logged In As: Citizen Request Management Wednesday,July202016 TOWN\oconnelt Route to Users Search Requests Create Requests Request Information Request ID: 56858 Created: 7/19/2016 10:20:04 AM Status: Assigned To Staff Assigned To: O'Connell,Timothy Health Office Anonymous: Yes Request Category: Chapter II : Housing Substandard edit Routine work: No Estimate: No edit Date scheduled: edit Estimated 8/2/2016 Change Estimated Jul August 2016 Sep Completion Completion Date: Sun Mon Tue Wed Thu Fri Sat Date: 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 #24L 27 303 6 10 Created By: Soto, Kathryn Priority: Medium edit Health Office Citation'Numbers: edit Requestor Information Requestor Request DETAILS: LOCATION: 98 PARK AVENUE Centerville, Ma 02632 Request Parcel Map: 208 !Block: 1135 !Lot: 000 Caller Number -- -------m--- — states address has Parcel Lookup an illegal apartment Email in the garage without proper egress or a kitchen (only a hot q v L;��' http://issgl2/internalwrs/WRequest.aspx?ID=56858 7/20/2016 TOWN OF BARNSTABLE •_ • �,:�r= 9g ���Kr !�� SEWAGE TLLAGE CeR W 1/lllt-f ASSESSOR'S MAP & LOT ZQ6-1 J, NSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0O LEACHING FACILITY: (type) ���G Dder� (size)® NO.OF BEDROOMS BUILDER OR WNER PERMTTDATE: q— � a COMPLIANCE DATE: Separation Distance Between the:. Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 7-2- _ 3 0 TOWN OF BARNSTABLE SEWAGE # ft12 2 VILLAGE C fj17W 1///`e ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L'e���l"4 (2499A. 6Wk (size) ;2 ZUU G.a NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 1�v z s COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or-within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(It—any wetlands exist within 300 feet of leaching facility) Feet Furnished by "- � \ ' �.t. �� 't'� : � -� ♦!! F f. l�__ � +� RECEIVED COMMONWEALTH OF MASSACHUSETTS 07 v EXECUTIVE OFFICE OF ENVIRONMENTAL AFF RSUN 2001 ,.j BARNSTABLE DEPARTMENT OF ENVIRONMENTAL PROT U1ti LTH DEPT. t � V TITLE 5 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: \' e z Owner's Name: Owner's Addre a Date of Inspection: _ Name of Inspector: lease print RrjoerA , QYf'1 Company Name , , Mailing Address:' C7o(P�/-8 Telephone Number:. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information rtported 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 . 4eeds F�rther Evaluation by the Local A roving Authority ailsInspector's Signature Date: �. p 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. Title 5 Inspection Form 6/15/2000 page ] ep Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9-e >Y JAP Owner: Date of pection:. /, Inspection Summary: Check.A,B,C,D or E l ALWAYS complete all of Section D A. S stem Passes: I have not found an infonnation y 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(Y;N,ND).in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or.the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection.if the. existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(§)are replaced obstruction is removed distribution.box is.leveled or replaced ND explain: The system.required.pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction.is removed ND explain: 2 c , t Page 3 of Il OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: AM Owner: Date of pection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in.accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which.will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public Health,safety and environment: _ The.system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within.a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank.and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well". Method used to determine distance "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: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION(continued) Property Address:AddepToZ71,9 Owner: Date of I ection: D. System Failure Criteria applicable,to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ tf/Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool Discharge or ondin of effluent to the surface of the ground or surface waters due to an overloaded or — b P g b / clogged SAS or cesspool Static liquid level in the distribution.box above outlet invert due to an overloaded or clogged SAS or lcesspool V Liquid depth in cesspool is less than 6"below invert or available volume is.less than %s day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number �of times pumped Anyportion of the SAS,cesspool or:privy is below high ground water elevation. Any portion of cesspool or privy is within I00.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 coliform bacteria and volatile organic compounds indicates that the well is.free from pollution from that facility and the:.presence of ammonia nitrogen and nitrate nitrogen.is:equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a.large:system the system must serve a facility with a design flow of 10.,000 god 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—I WPA)or a mapped Zone II of a public water supply well If you have answered yes to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system.in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 f , 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART B CHECKLIST Property Address: 9 Owner: Date of pection: �3/�d! 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 jZ 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? -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 breakout? _LZ_ 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: Yes no Existing information.For example,a plan.at the Board of Health. jZ— Determined in the fie id(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of 11 OFFICIAL-INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION Property Address: b" to Owner: Date of. pection: J / FLOW CONDITIONS RESIDENTIAL✓ Number of bedrooms.(design). Number of bedrooms(actual): DESIGN flow based on 310 C R 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence.have a garbage grinder(yes or no):-AV— Is laundry on a separate sewage system (yes or no t .[if yes separate inspection required] Laundry system inspected(yes or no)- Seasonal use:(yes or no�):,1�� Water meter readings, i v1`'a ailable(last 2 years usage(gpd)): Sump pump(yes or no ��/� ✓ ®' ^- �®, ^� Last date of occupancy:A - V w �u K1CrJC.C// COMMERCIALANDUSTRIAL� Type of establishment:. Design flow(based on 310 CMR.15.203): gpd Basis of design flow(§eats%persons/sgft,ete:): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):-_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source:of information: Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons--How was 4uantitYPun ed determined? Reason'for.pumping: TY"F 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) _Tight tank _Attach a copyof the DEP,approval _Other(describe): A roximate age of a components date installed(if known)and source of information: Were sewage odors-detected when arriving.at the site(yes or noL `• 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION(continued) . Property Address: (PO Q Owner: Date of pection: � BUILDING SEWER(locate on site plan)`/00 Depth below grade: ' Materials of construction:_cast iron _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: Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed.by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: JQ,S a11� ' k Sludge depth: Distance from top o sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 3 Distance from bottom of scum to bottom of outlet tee or baffle: l How were dimensions determined: Comments(on pumping recommend'ationsf inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.)' GREASE TRAP-TRAP: cate on site plan) ��G �% P/IGe�/1�i� J�✓� �u2j ' Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet.invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(continued) Property Address: / .4 Owner: Date of pectioni u/a7/D 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:Zif 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,any evidence of kaoe into or out of box, etc,): PUMP CHAM ER (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.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: aJ6 Owner: Date of pection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching.pits,number:_ eaching chambers,number: o� 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): 7Lj X& i� 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 or no): Comments(note condition of soil,signs of hydraulic failure,•level of ponding, condition of vegetation,etc.): PRI;yyvA&�'(locate on site plan) Materials of construction.- Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)- 9 Page 10..of 11 OFFICIAL.INSPECTION FORM=NOT .FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:, _ �"1-0 Owner: Aj Ai, . Date of I pection: �/g//n 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: ou, y S 7 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART .0 . SYSTEM INFORMATION(continued) Property Address: �IA Owner. Date of spection: SITE EXAM Slope Surface water Check.cellar Shallow wells Estimated depth to ground water 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) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database=explain: You must describe how you established the high ground water elevation: , '4 ]1 No. Ylt a!mot 1d Z Fee �S✓ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pprtcation for Mi5p0al *p5tem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( t//)an On-site Sewage Disposal System at: Location ress or Lot No. Owner's Name,A dress and Tel o. g� /�r/z lvU� Sew fi-067#d� C ely, �111e ®Z6 Z_ t Installer's Name,Addre s,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder(14le Other Type of Building �,� Bd7ee No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 11,15 gallons per day. Calculated daily flow 7� gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) e -el !0 `�� ,^ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is B f He �� Signed Date Application Approved by Application Disapproved for the following reasons Permit No. '' Date Issued �D THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS i Certificate of (Compliance THIS IS TO CER)JFY,that the On-site Sewage Disposal System installed( )or�rrjpaired/repla-ed((,4 by d f % l'C��1.� - for ore'!w as 6' lPl' f rlPI'l/ �l has been construct d in accor ance with the provisions of Title 5 and the for Disposal System Construction Permit No: ,�'• dated s" _ y� Use of this system is conditioned on compliance with the provisions set forth below: a 0 No. ci'ems Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Miopogar *pgtem Cow6truction Vermit Permission is hereby granted�to !J�� �4 C �6✓u to construct( )repair( �/)an On-site Sewage System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: �`^ 7 % Approved b —'` No. � ? 1 Fee - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 4[pplication for Mi.5paal *pgtem eongtruction Permit Application A hereby made for a Permit to Construct( )or Repair( 14an On-site Sewage Disposal System at: Location Ad ress or Lot No. Owner's Name,Address and Tel o. C ee - vil/e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. A, i'�"oCoi C©�s Type of Building.Dwelling No.of Bedrooms 3 Garbage Grinder Other Type of Building .e,5 , z°%ee No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //� gallons per day. Calculated daily flow J gallons. 1 Plan Date Number of sheets Revision Date II Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) � G tJ^ D — ®d �D9' ��G/y e^.3 Alkfz 2 b ' © 71DAe Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is B f He Signed A Date /�4�_ Application Approved by ' rl Application Disapproved for the following reasons Permit No. Date Issued '` O — — ——— — - I h ' -r' CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT OVITHOUI' DESIGNED PLANS) --dy,�hereby certify that the application for disposal works construction permit signed by me dated �` Z/! Q� concerning the property located at 916 le a'le" Ceh*,1,V1 Ile- Meets all of the following criteria: /Thcre arc no wetlands within 300 feet of the proposed septic system T cre arc no private wells within ISo feet of the proposed septic system The observed groundwater table is 14 fect or greater below the bottom of the leaching facility here is no increase in flow and/or change in use proposed There are no variances requested or needed. SIGNED: DATE: LICENSED SEPTIC STEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also If the licensed Installer posesses a certified plot plan, this plan should be submittedl. MOVIE `'S t ��Y \' ta� 4U5 �, � �� �� � � l , � C� ��'1 �' �l �� O Q o 0 �l�' ��.r�-�c�i,cs.-�- � ���� r.