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HomeMy WebLinkAbout0387 PRINCE HINCKLEY ROAD - Health (2) 387 PRINCE HINCKLEY, CENTERVILLE -- - -- A= 171 - i I Commonwealth of Massachusetts . Title ,5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary)ssessments .'" 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is Centerville. MA 02632 10/01/07 . required for 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. Important: A. General Information , When filling out L` 1 forms on the computer,use 1. Inspector: only the tab key. to move your • Robert J..Bortolotti. � cursor-do not Name of Inspector use the return key. Bortolotti Construction, Inc. Company Name P. O. Box 704-45 Industry Road Company Address Marstons Mills MA 02648 City/Town State . Zip Code 508-771-9399- Telephone Number License Number { B.�Certification certify that I have personally inspected the sewage disposal system atthis address and that the information reported below is.true, accurate and complete as of th'e time of the inspection. The inspection was performed based on my training and experience in the proper,function and nn fintenance 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 I ; Passes ❑ Conditionally'Passes J ❑ Fails ❑ Needs Furth Evaluation by the Local Approving,Authority 16 T7 lye 1 ertots Signature pate fiThe system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the.appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority.`' ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments, ; 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is required for Centerville MA 02632 10/01/07 every page. City/Town State Zip Code Date of Inspection B. Certification (coat) Inspection Summary: Check A,B,C,D or E/always complete all of SectionD A) System Passes:, 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 evoluated.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(s) are replaced ❑ obstruction is.removed t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•..Page 2of.15 r ` Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is required for Centerville MA 02632 10/01/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cost.): ❑ 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: 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. t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts w W Title 5 Official In a spection Form ; a a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 387 Prince Hinckley Property.Address Donald Mason Owner Owner's Name information is required for Centerville MA 02632 10/01/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required-by the Board of Health (cont.):. ❑ 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 we Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified,laboratory, for coliform bacteria indicates absent and the presence of.ammonia nitrogen and nitrate-nitrogen is equal to or less than 5 porn, 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 ❑ ElBackup of sewage into facility or system component due to overloaded or clogged SAS or.cesspooi ❑ ❑ 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 El �" Liquid depth in cesspool is less than 6" below invert of available volume is.less than Y day flow - Required pumping more than 4.times in.the last year NOT due to clogged or El ❑ 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 EJ tributary to a surface water supply. t5insp•.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I i - Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information for tion is required Centerville MA 02632 10/01/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria`Applicable to All Systems (cont.): Yes No ❑ ❑ 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 4.00 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. t5insp•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official ,Inspection- Form s Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments M 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is Centerville • MA 02632 10/01/07 . required for State Zip Code Date of Inspection every page. City(rown, p C. Checklist Check if the following have been done. You must nd icate"yes".or"no" as to each of the following: Yes No ® ❑ Pumping information.was provided by the,owner, occupant, or Board of Health ❑ _ M 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 FJ ® this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the-facility or dwelling in.spected.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 pP p ) [ Ol 15insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15. I 1 Commonwealth of Massachusetts wV7. Title 5 Official "I nspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is required for Centerville MA 02632 10/01/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): ���oc�o o( � V,j'e®o Sump pump? ❑ Yes ® No Last date of occupancy: current 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: Last date of occupancy/use: Date Other(describe): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information Centerville MA 02632 10/01/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped 1.0/15/04 by Bortolotti Was system pumped as part of the inspection? ❑ Yes M 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 inspectioarecords, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ' ❑ Tight tank. Attach a copy of the.DEP.approval. ❑ Other(describe): .Approximate age of all components,,date installed.(if.known),and.source..of information: Home built in '84-original system Were sewage odors detected when arriving at the site? ❑ Yes ® No 15insp•08/06 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•,Page 8 of 15 i Commonwealth of Massachusetts w Title 5 Official Ins � �ection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is required for Centerville MA 02632 10/01/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 16" 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 10.5' x 6' x 5' Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 4„ 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 1® � How were dimensions determined? physical observation t5insp•08i06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 115 i r Commonwealth of.Massachusetts w W Title 5 Official. Inspection Form . p o Subsurface Sewage,Disposal System Form Not for Voluntary Assessments �M 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is required for Centerville MA 02632 10/01/07 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.)- It's a 1000 gallon precast septic tank with covers 16"to grade with plastic inlet and cement outlet tees, it has 4" scum and 3" sludge at time of inspection. .Tank was pumped following inspection. Grease Trap (locate on site plan): Depth below grade: feet: - Material of construction: ❑ concrete El metal ❑fiberglass, ❑ polyethylene. ❑ other(explain): Dimensions: Scum thickness Distance from top of.scum to top of outlet tee or baffle Distance,from bottom of scum to bottom of outlet tee or baffle Date of last.pumping: ; Date' Comments (on pumping recommendations, inlet and outlet tee or baffle condition; structural integrity,, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at,time of inspection),(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal El fiberglass ❑.polyethylene- ❑ other(explain): t5insp•98106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 5 Commonwealth of Massachusetts W Title '5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is required for Centerville MA 02632 10/01/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No bate of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level'above outlet invert Working Level Comments (note if box is level and distribution to outlets equal;any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The distribution box is 24"to grade and was at working level at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No l5insp•06106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is required for Centerville . , MA 02632 10/01/07 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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: 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 ondin( g y , dam soil;condition of p 9 p vegetation, etc.): It is a 1000 gallon.precast leach pit with covers 1'8" and top of pit 36",to grade, it had 10"water at time of inspection with no staining indication of being any higher,. t5insp-08106. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15: Commonwealth of Massachusetts r Title 5 Official_ Inspection Form a s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,.' 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is required for Centerville MA 02632 10/01/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of.Massachusetts W Title 5 Official Inspection Form v Subsurface Sewage Disposal.System Form- Not for Voluntary Assessments 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information isCenterville MA 02632 10/01/07 required for every page. City/Town` State Zip Code Date of Inspection D. System Information (cont.) 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. cF 7 -7, a ico III o f �X 000 (�c� t5insp•06106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 387 Prince Hinckley Property Address Donald Mason Owner Owner's Name information is required for Centerville MA 02632 10/01/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: / 7 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) Q� Accessed USGS database -explain` You must describe how you established y the high.ground water elevation. l5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 f Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Lot No. Owner: Ale Address: Contractor: Address: i STEP 1 Measure depth to water table to nearest 1/10 ft. ................................ ......... ....................... ......:.. Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: 0 Appropriate index well...:::................ O'Water-levee range zone .................... ........ ......... ...::. N STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to QS,/�� water level for index well..:....:................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 26) o determine water-level.adjustment ........ . ...... .. ................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ............................................................................................................. 0 p Figure 13.--Reproducible computation form. 15 �- 00. -� .O- > IF 5f a , 5a rjc � �- oF1HE r� Town of Barnstable Regulatory Services snRrsrnst a Thomas F. Geiler,Director A�F039. Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. l Certified Mail#7005 1160 0000 0191 2403 P,ofIKKE ti Town of Barnstable Regulatory Services RARIVSCABLE. 90 MASS. Thomas F. Geiler, Director O 1639. ArEOMA�p Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 11, 2007 Donald &Norma Mason 387 Prince Hinckley Road Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II - MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 387 Prince Hinckley Road, was inspected on May 10, 2007 by Meredith Morgan, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the Town of Barnstable Code were observed: 170-10—Smoke Detectors and Carbon Monoxide Alarms. Inoperable smoke detector in basement. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by repairing or replacing smoke detector in basement. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. QAOrder letters\Housing violations\Rental ordinance\387 Prince Hinckley Road.doc Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH omas A. McKean, R.S., CHO oma� Director of Public Health Town of Barnstable Cc: Meredith Morgan, Health Inspector QAOrder letters\Housing violations\Rental ordinance\387 Prince Hinckley Road.doc 1 ,a • r—F ::.I --fir �.,._.. U:S:Postal ServiceTM CERTIFIED MAILTM RECEIPT 1 (Domestic Mail Only;.'No Insurance Coverage,provided) cl =W 1 For delivery inf&niation`visit our web§ite at www.usps com®','l. W 00 :0 ��� '=0I..LL wyl� LL Owl 'azxm:` I 1: W 71 `Y ywl - w 1 ULL 1 �_I� PS Form 3800.June 2002 1 _ .See Reverse for Instructions Certified Mail Provides: (as�anay)ZOOZeunr`OOBEwJuj Sd s A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. 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Article Number 7005 1160 0000 0191 2403 (transfer from service label) PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540I l UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • I - 1 Town of Barnstable TOE Health Division j 200 Main Street Hyannis,MA 02601 i I i AW HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS FORM 30 C ARD OF HEALTH CIT /TOWN W b D RTMENT, I �1 S CPD ADDRESS G�M0 ���// J�,. ,/'/ �J T LEPHONE AddressJ6;0_ri N� rI Xje K.l� Occupan Floor Aparim nt No. No.of Occu nts No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming un No.Stories Name and address of owner .d-°I �G✓�(Q• �5�/Y) �l/t � r-I/� ���-ar. Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: _ Dampness: 25 1 n / Stairs: Lighting STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters, Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den —Living Room Bedroom 1 ., Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink ° Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALT fto �m 11 INSPECTOR TITLE C,TV 1 A.M. DATE TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION 7M P.M. 410.750:...Conditions Deemed to Endanger.or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A),410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or'trash,which prevents egress incase of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. TOWN OF BARNSTABLE LOCATION 3 #/4G�-le Y' /'d SEWAGE# 95-17d' VlI.AGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. ©J���//%f 771"�J�ey SEPTIC TANK CAPACITY boa® 4k ,LEACHING FACILITY: (type) + (al x % (size) 8 NO.OF BEDROOMS BUILDER OR OWNER �✓�� PERMITDATE: la-2-0- J 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 Pr 1-- 30 0. zq — Sol of 3 i 02 No. / 2 /7 77 FEE -.r THE COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS �Nyyfirafivu for Pieposal '�igstem 01onstrurttun jJermit Application is hereby made for a Permit to Construct ( ) or Repair(Vfan On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 601_171K,�i Goyyf-r'�rctiv� .�,44,7rr Type of Building: Dwelling No. of Bedrooms 3 Garbage Grinder Other Type of Building No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //D_ °1�,4 96'�/'Lfgoa llons per day. Calculated daily flow 3 3 69 gallons. Plan Date.. l`/2 `$y Number of sheets l Revision Date Title Description'of Soil Nature of R pairrs or Alterations(Answer hen a plicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction f the aforedescribed 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 Certificate of Compliance has bye .ss b this Board of Health. Signed Date h _Z!]��✓� Application Approved by Date I& Application Disapproved for the following reasons Permit No. / i� '� 1 / �� Date Issued -...�;.a- ;� : ...;ter• � � .�. . . .. - - ., � .,,�. ��',.�� � � � .r' a`. 777 No. L FEE _ THE COMMONWEALTH OF MASSACHUSETTS � r�stg�le MASSACHUSETTS , lNpp i ativn for jBisposal Sgstera Tortstrurtion jJermit Application is hereby made for a Permit to Construct( ) or Repair(V�an On-site Sewage Disposal System at: Location Address or Lot No. /J Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. S'PrtOGef l' GO�yf-r�rCt%�� �A � Wye 7 6 S'Gv0*/oy -" Type of Building: Dwelling No. of Bedrooms 3 Garbage Grinder Other Type of Building No, per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1/0 90//Ozlo Pe'.1- ons per day. Calculated daily flow 33D gallons. Plan Date �`/2 - 0-y Number of sheets Revision Date Title Description of Soil { fI1irAe t° 1��5f®�r 'mo- o Nature of Repairs or Alterations(Answer he a plicable) h k46 f Date last inspected: Agreement: The undersigned agrees to ensure the construction f the aforedescribed 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 Certificate of Compliance hasabenASS b this Board of Health. Signed ` "` Date Application Approved by A Date C Application Disapproved for the ollowing reasons Permit No. / Date Issued a THE COMMONWEALTH OF MASSACHUSETTS r v`�Z _M , MASSACHUSETTS (9er ifirate IIf (fantylianre THIS IS TO CERTIFY, that the On-site 5ewage Disposal System installed( ) or repaired/replaced(Vl on by 1_"rd ® I"/�c %O for at .S 5K ,Or/dGG 191'/1G L/z-Y 6 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �? - /7 Z,9— dated Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee . the system will function as designed. This Certificate expires on DATE �. Ins et©r' THE COMMONWEALTH OF MASSACHUSETTS No. 75� dr�57L�6/� , MASSACHUSETTS FEE - ptspusal Sgstrm (gons#rnr#tun jJernti# Permission is hereby grant to &f/ D GO / C��``����C I to construct ( ) or,r pair( an On-site Sewage System located at -K 7 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 three years of the date below. DATE �� Approved by FORM 1255 Rev.3/95 A.M.SULKIN CO.-BOSTON,MA p4 I 5lw6LC FAMIL*`' - ;3 BC- UROoM i 1.10 :6AR0�GE-G�IJDE2 ; II DA1l.Y FLOW s 110A 3 = Z30G.P. D )� SEPTIC, TAQK = a3o><15o h II USE 100o GAL. • ,_: � �' ,I D15PoSAL PIT t�4E 1000 GAL. �� :. :•.> 1- �o�3ss . �5o S.t 2.5 375 G.PP , . . BoTTo/K AREA] ,rt o 5 r• � ;�. 5p S.F x I• o � 5p G.P c?' � � ' • II -ToTA L. C 5.$16N q•2 5 G.P D. �4 a-TOTA%- AA I I.Y FLC>V4 - 33o 6.1?0 �' ymP II P,,. ,.GC,.. . , .�• �, PE2COLATION GZATEi 1''IN VAINOf oRL�55► 1 se- N OF *' RICHARD G �r o`er AI.AN DAXTER H w �Ur�r.s , .'� i ;, Na 210480 , 1_•i m , t'', AA -47 su �oAD TS-�;T P 243q To P FAtp, I IEL-+ cL - � IRV. Sc�. II -AqqKvX91ct 100a Svssoll� eSx 23-4�0 el r S�•B 4 ,,�DIle d00 INY TANK i 5 .v /o LEAcu PIT INV. INV. / WITu �3•L �3•t ly3/4.1% 4 I` SA1JD� WAt,"GD 6TvNG I CERTIFIED QLoT PI-A-W II PROFILE ' rY Wo v— P� A N R E F S IzEN GE TIFY 'THAT 'THE I'pU�� c : t,"oWN ►{E, sow GOMPL�(5 WITN'TI-IF6 SIoti~L1r-1 �.�j'� 6p AWP S6T5ACK R,6Qv1Q.EMENT> F 'f1�� lc>W N or- -tJ AJZi,KTA FUaA N D 1 S NGi LOCp.TE D ITNIN T E Ir LOOD PLb-I W sceo pio • DATE Ct i� BAxTEze Wye: INC. -c�Qtz�'I.A,N D S u 2v�Y�eS I REGIS , AN OSTER.NILL& - MASS• , IW,5T?-uMEN"r 5v2VeY �-TNE Dt=F,SE'T5 Suout,� No-T DC- u5EOTC1 C)eTE APPLICA►-IT / BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 0 O 508-771-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL T �SYS EM INSPECTION FO PART A N~ CERTIFICATION Property Address: Date of Inspection: Inspector's Name: Owner's Name anq Address. ,G? , ill r1 . CERTIFICATION STAT . F.NT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal items. The System: Passes Conditionally Passes Needs Further Ev do the al Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY.• A)SYS ,SM PASSES: V I have not found any information which indicates dial the system violates any of the failure- criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or enfiltmtion,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The. system will pass inspection if(with approval of The Board of Health): • - I- f .. ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Y Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four 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 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT'PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 private water supply well unless a well water analysis for coliform Feet or more from a PP Y P bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. - D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. ' Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. . Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded ouclogged SAS or,cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool,., Liquid depth in cesspool is less than 6"below invert or available volume is less than U2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). .Number of times pumped -2- s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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.The owner or operator of any such system shall bring the system and facility into frill compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if following have been done: ping information was requested of the owner,occupant,and Board of Health one of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. c`As-built plans have been obtained and examined. Note if they are not available with N/A. the facility or dwelling was inspected for signs of sewage back-up. the system does not receive non-sanitary or industrial waste flow. ,the site was inspected for signs of breakout. 11 system components,excluding the Soil Absorption System,have been located on site. __jZTWe septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for,condition of baffles or tees,material of construction;dimensions,depth of liquid, �of sludge,'depth of scum. srze and location of the Soil Absorption System on the site has been determined based on existing information or approximated-by non-intrusive methods. -3- e i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) !/The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESMENTIAL! " Design Flow:��gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder:�U Laundry Connected To System: z Seasonal Use: 126 Water Meter Readings,if available: Last Date of Occupancy: Cl t"OMMER AIAND 14T IAL., Type of Establishment: Design Flow: . aallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER Describe) Last Date of Occupancy: GENERAL INFORMATION c � PUMPING RECORDS and source of information: 9Jl System Pumped as part of inspection:_ if yes,vol pumped:;- pall ns Reason for pumping: TYPERF SYSTEM: Septic TanWistribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy "Shared System(If yes,attach previous inspection records,if any) Other(explain): P O TE AG fall CpWonents date installed(if known)and source of information: " Sewage odors detected when arriving at the site: an -4. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • x 'PART C , GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: " Material of Construction: l�concrete metal FRP_Other (explain) Dimisions:(S S� 1((e ' XS Sludge Depth: _Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 7 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation t outlet invert'structural inte ri evidence of leakage.etc-) 1 l� - ii �� GREASE TRAP: Depth Below Grade: Material of Construction:—concrete_metal_FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage.'etc.)" TIGHT OR HOLDING TANK:-Z-06 Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: >;allons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments:(note if lqvel and distribution is equal,eviden a of solids carryover,m n.9e of leakage into or,put of box,etc. c c� PUMP CHAMBER: Pump is in working order:— Comments:�(nioite condition of pump chamber''condition of pumps ond'appurtenances,etc.) ' �l"M a'4 V A..xlry f,�S. 4 • � �S.a`.'[.�'' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation.not required,but may be approximated by non-intrusive, methods) If not determined to be present,explain: Type: Leaching pits,number: 1 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: etc ommeT:(note condition of soil,si s of hydraulic failure level f ponding, ndition of vegetation, �J' l it CESSPOOLS:_.L1) 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(Cesspool must be pumped as part of inspection) Comments:(note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: ...... Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) _. .6. _ s . i y i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atieast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 2 CY G I DEPTH TO GROUNDWATER: Depth to groundwater: /5' Feet bledloo—of Determination or Approximation: -e), -7- LOCATION P SEWAGE PERMIT NO. r pit V I I L A G E �,enk gyre% INSTA LL Zbe, drr S NAME i ADDRESS " 6. ou2 CCU- I �1C. 6 U I L D E R OR OWNER A LAIC .S LL- FDA T E PERMIT ISSUED DAT E COMPLIANCE ISSUED la f�®��.SaQo � �� � W t o .. �� �� �I9" �® 3� s , .......12....... Fss... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA ,TOH- . ...........0F............................................................ Appliratiuu for Mipmal Works TolUitrurtiurt rnmit Application is hereby made for Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ......... .. .. -- S-- ------ •---........ Loca Address ' . _-_ Lot No. ......................... .. ........ ......................... a Owne/r � Address Installer Address dType of Building Size Lot.... �.trA.Sq. feet U ...........................Ex ansion Attic Garbage Grinder., Dwelling—No. of Bedrooms.............. .. p ( ) g aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow........... ----------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No/.. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........./Q' 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........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ----•-----------------------------------------•-•------.............------....................------.......................................................... 0 Description of Soil......................................................................................................................................................................... x --------------- --------------------------------•-------------------------------------------------••----•--•---------------1-•---------------------•-•--•-•---------------------•-•-•-•--------------•-. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------------------------------------------------•--...---•----•----••---....----------------------•---•---------•--------•---•--•--•--•--•-•-------....------------• Agreement: undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the r isious of TITI.L 5 of the State Sanitary Code— The undersigned f ther agrees not to place the system in o er n til ifi of Compliance has been iss ed by the bpard of Walth. Ap li t Approved By-------�------ -----------•---•------..------------- ....1 �Y--................... A ication Disa roved 0 12C Date PP f lowang reasons: . ........................ --.....---•----------------•----------------•-----...------------•---•----•--•---------•---...-•--------•..---••---•-----•--------••------••-•-------------------•--------•• ............................ Date PermitNo......................................................... Issued....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA I Nby ----•- Fxs...,"s.��:............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFF HEALTH r ✓ X.ee.-41I.?­1.............OF ". AVp iration for Bhiposal orkri Tonotrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .................................m................................................�f�......!Y / t, f' Locattion?Address r ' or'Lot No , 1 r �+ j _ Owner Address _.�s .. r.... ....-N .......... 'ram 'r€c-'� .... ..................... Installer Address Q Type of Building Size Lot____ y",__;_=:_ -.Sq. feet U Dwelling No. of Bedrooms.............::'. ' E g— ..........................Expansion Attic ( ) ,,,. Gac ge Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures .............................................•-...........................---••-------------••--•---.............----•........................._•-•-•- Design Flow............ ................gallons pg person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid"capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width...........1Z.-- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.__.._..; ",..=.:.: Diameter..............: :.. 'Depth below inlet.................... Total leaching area.................. ft. Z Other Distribution box (<' )' I�T Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth-•to ground water........................ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.......- epth to ground water........................ ----•--------------------------------------•---.....----------......--•--•----•-----•--•-•-•••.............................................................. xDescription of Soil........................................................................................................................................................................ IJ •---------•---••-•......•-••••-•••-•................••--•-•--•-•........-•----••---•••........-•-•••....•--•-•----•-•-•......-•---•-••••----••-•--------••-•..............-----••----------••.........•. W -----------------------------------------•-----------------------------------------------------••----•-----•--•••-••-•••-•------•--•--•---•--•••-------••----••------•-----•-•-•....---•----••.------ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... . . •-•-•••-----•-•-._....-•-•................................................. Agreement: Tfi undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the .pr isionsofTITLE 5 of the State Sanitary Code— The undersigned i Llther agrees not to place the system in o,er n ntil ertifi e of Compliance has been issued by the bgard of health. ; Si ed. ...........<. tom. ...._..._ Appli ti Approved By---•---• -••--_... .•---------•--••.........•--•--........--•---••--•• 1 . . ! Date A ication Disapproved for .The lowing reasons:-------•-------• ........................••--•--•--------------••-------------•--...-----........._:.................---- .......•---•--•--•-•••-•-•----•-•------••--•-••-----••••----------•-•---••••---•----•-••.....----•--••-•-••-------•......................•••------•---•---•-........................................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifiratr of Tout;t iatta T IS TO CERTIFY, That the Individual Sewage Disposal System constructed (__ or Repaired ( ) F by............. ( ............. --------=------------- -- •- --....... ----- ---------....._.... .-----..... ------- has been installed in accordance with the provisions of TI 5 of The State Sanitary C e as •cribed in the application for Disposal Works Construction Permit No...... .._. ...... dated_._c.. _.�._......................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM WI ` CTION SATISFACTORY. �a DATE...:?l!..-'�- ................... Inspector----- _ ...--------•-•.......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L � X OF..................................................................................... No. ...................... FEE........................ Bisvosat k ion #rnrttion rruti Permission is hereby granted..........1.).. .. •. �:. ............................ .......... 1-1 to Construct ( )�a Iv' al Sewage os 'System at No................... <2..- LM�sr S.. as shown on the application for Disposal Works Construction Permit No....... ...... ..• ed.......................................... ...................................... ........ ....................................................... DATE............. ?' ...--- _ d of Health FORM 1255 A. M. SULKIN. INC.. BOSTON F AM t LY - ;5 B C 0 Q 0 oM Flow I 10 x 3 x 3 5EPT%C,- -rAQK = 33Ox 150-/- .4 9 0 USE - 100c> 6A%-. C>%5PD5AL PIT v4i: loon 6,4L-. BOTTOM A9-F-A-- .. Y0.6.F, 70TAI- Ds5i(lwv .4215 G.P. D. 64 44--A 'TOTAL r->A%L-Y FLDW = 3306,PD PaP-COLATIOW P-ATS ; 1"Ito ?-fth) or--Lf:-55, se- MAJAIL if V OF t.4 A I ci AL N iCHARD A. Jot 4 Es BAXTER 110 21M too IST' su -ro p Fgt:;,s-S 7 li .s �� - ^ INV. D I ST. INV. DuX c,EP'riC lwv LE.A.C%4 pl-r INV. INV. WITW 3/4-1 VL WAt,%4rD 6,170 H C- !) PRUFIL� Lts W 0 SCALE 5 CA L C- 0 WATCV— L..4.N lz F= AWD -$�T5•CYC 70 W W 0 P: _MP krZ-i-4e7TA F31-SA WD 14, LOC-,&.TEO -14YlT"lVJ TqS t:L000 NYE INC. f--Zr-,D't-Aw D-5 u?-V E:Yc> -r"ll.$ PL&KI 1!:P KlOrr 5N5r=y� 4>I'd AKJ A4066- u 9-V e Y 'THE 0 s,-,rSF-76 C)e7eF-/t�l),AG L.Q-'r A P P L I(�,C6,I`-J'r