HomeMy WebLinkAbout0069 SOUTH MAIN STREET - Health (2) 69 SOUTH MAIN ST.
CENTERVILLE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is CENTERVILLE MA 02632 2/5/13
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. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN U
cursor-do not Name of Inspector
use the return
key. DOUGLAS A BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
City/Town State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification -�
I certify that I have personally inspected the sewage disposal system at this add'reys and thefithe
CD
information reported below is true, accurate and complete as of the time of the ins I'— t�Jon. T inspection
was performed based on my training and experience in the proper function and intenanc4f owgi e
sewage disposal systems. I am a DEP approved system inspector pursuant to section 15.340 f
Title 5(310 CMR 16.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails:
a
❑ Needs Further Evaluation by the Local Approving Authority
Gi 2/5/13
Inspector'4PSignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
�J
t5ins-11/10 Title 5 Official I&ion Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
W Tide 5 Official Ms ectoon For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
LEACHING SYSTEM WAS NOT OPENED NO OBSERVATION PORTS FOUND
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM , 69 SOUTH MAIN ST
Property Address
KOURI
Owner Owners Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
1
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory., for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent.to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 2/5/13
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a'DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
_ I
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)] .
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND A
10X40X1.5FTS.A.S AS-BUILT ALSO SHOWS A PIT AS WELL
Number of current residents:
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)):
Detail:
2012--------290 2011-------361 GPD
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 69 SOUTH MAIN ST
Property Address
KOURI
Owner Owners Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes Z No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
y ® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M a 69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
S.A.S INSTALLED IN 2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 GALLON
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
w . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? WOODEN POLE
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK COULD USE PUMPING AT THIS TIME
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
BOX LEVEL NO LEAKAGE SHOWS SOME SIGNS OF CORROSION
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
NO OBSERVATION PORTS
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑, leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: .
10X40X1.5
❑ 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.):
NO OBSERVATION PORTS FOUND SO WE COULD NOT DETERMINE THE LEVEL OF PONDING
IN THE S.A.S
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
'Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 SOUTH MAIN ST
Property Address
KOURI
Owner Owner's Name
information is required for CENTERVILLE . MA 02632 2/5/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 40
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water,elevation:
OFF ATTACHED SEPTIC AS-BUILT
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4M , 69 SOUTH MAIN ST -
Property Address
KOURI
Owner Owners Name
information is required for CENTERVILLE MA 02632 2/5/13
every page. CityrFown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E ►nspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information— Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Assessing As-Built Cards 20F Page 1 of 1
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LOCATION 1Q g SEWAGE# o o- 7/7
VILLAGE Gen/ VR V I V ASSESSOR'S MAP&LOT`AAg115
INSTALLER'S NAME&PHONE NO. Me jg N
SEPTIC TANK CAPACITY d
LEACHING FAciLrr .(type) x g&:. (size) %U.'I V e*/L
NO.OF BEDROOMS Y ._
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility #o 'Y, Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) zlu� Feet
Edge of Wedand and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) ;'1/Yi�/s' Feet
Furnished by
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http://www.town.bamstable.ma.us/Assessing/IfMdisplay.asp?mappar=228125&seq=1 2/6/2013
TO OF BARNSTABLE
LOCATION & 9 .; 6cd I rN C-'F SEWAGE # _10 J 0— 7f 7
'%r,iLLAGE ��/'U �� °d ��ti" ASSESSOR'S MAP & LOT .
INSTALLER'S NAME&PHONE NO. �`;�'_' ___
SEPTIC TANK CAPACITY lv t:> J
LEACHING FACILITY: (type) oL (size) L'1-P
NO.OF BEDROOMS
BUILDER OR OWNER ✓n r G
PERMITDATE: 4/40�2—cOMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
i
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) ✓1�f,?`/� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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11. 0CATION SEWAGE PERlAIi NO.
VILLAGE
IMS. A LLER'S . ' NAME i ADDRESS
G U I L D E R OR OWN ER
HATE PERMIT ISSUED
DATE CUMPLIANCL ISSUED.
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No. Z000 '—7 11 Fee 0 ;
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYicatiou for Migpogar *pgtem Com5truction i3ermit
Application for a Permit to gntruct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
LocGo�d¢ ss o �� Owner's ame,A res and
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) -!,71a4j' "¢ 70
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 Tit f the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this o d of I lth,lij L
Signed /' l•�••~._ Date
Application Approved by ��.QJI.i.� C k"L-P Date 1aJ&100
Application Disapproved for the following reasons
Permit No. ZOO 0 —]17 Date Issued
� �� Fee 50 qs
THE COMMONWEALTH OF MASSACHUSETTS Enteredin computer:
- `.: `PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplicatton for ;Di2;po.5a1 *potem Construction Permit
Application for a Permit to C n7ruct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
SAC)- 0419A
Location, r,1fss o NS��v Owner's ame,A41 res
Assessor's M�a p[Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Y
Type of Building:
Dwelling 'No.of Bedrooms Lot Size � sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures -%
Design Flow gallons per day. Calculated daily flow gallons.
' Plan Date Number of sheets Revision Date
�1 Title
Size of Septic Tank Type of S.A.S.
Description of Soil
F
r Nature of Repairs or Alterations(Answer when applicable) /o k, yDx
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' f the Environmental Code and not to place the system in operation until a Certifi-
cate_of Compliance has been issued by this o d of Ilth
Signed "`�"" Date
Application Approved by )Ccx,.+mot Gk uZtP Date /3 D U
Application Disapproved for the following reasons
Permit No. 2 00 O -'I"7 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( )
Abandoned( )by 7_z2 171,ze ,Kv
at .z'" has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. Zoo O-�I dated
Installer Designer /V r N
The issuance of 's .e it sh'11 not be construed as a'guarantee that the to 01�uncuspn as`/hsi ne4dtDate J � � �e''"(64V� Inspectory gJ
l 1,
------------------------------------C---
No. ZODO `7I-2 Fee J a w
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi000al 6potem Construction Permit
Permission is hereby granted to Construct( )Repair(X Upgrade( )Abandon( )
System located at A sou- I-i M W 1 N ST. , "C?✓�1' fZVI U,.�
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. _
Provided:Construction must be completed within three years of the date of this permit.
Date: Approved by �tAl/L 4c� Sc5t ,kl p
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated Z 2 ��1� _ 207,J , concerning the
property located at : ' !F J 4f., <,,, ;7 meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is.classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) S
B) G.W. Elevation +the MAX. High G.W.Adjustment. _ O
DIFFERS TWEEN A and B
SIGNED : a DATE: !.� — d��
[Please Sketch pr osed plan f system on back].
7'
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
Cr
7
i
/ 6
01
SENDER:COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Si re
item 4 it Restricted Delivery is desired. X A AOAgent
■ Print your name and address on the reverse � ❑Addressee
so that we can return the card to you. B ecelved y(printed Name) C. D e of Delivery
■ Attach this card to the back of the mailpiece, IfE I
or on the front if space permits.
1. Article Addressed to: D. Is d livery address different from item 1? Yes
If YES,enter delivery address below: ❑No
/l vA p Z C fl J s 3. Service Type
l;Certified Mail ❑Express Mail
❑Registered 40 Return Receipt for Merchandise
r
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?Pft Fee) ❑Yes
2. Article Number ;; i i _:` - — -- - --- {--
(I)ansfer from service la,ieq ` {{ i!s i7 0 0 6 31:5 2 1 t (�
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
I
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
Permit No.G-10
I
I
• Sender: Please print your name, address, and ZIP+4 in this box •
� 4 Town of Barnstable
Health Division
200 Main Street
Hyannis,MA 02601
I i
Certified Mail#7006 0810 0000 3525 3152
VE
Town of Barnstable
Regulatory Services
,g Thomas F. Geiler,Director
9°a
Public.Health Division
Cog,A�,-
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
November 6, 2007
Richard Callahan
770A Main Street
Osterville, MA 02655
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 69 South Main Street Apt. #2, was inspected
on November 6, 2007 by Timothy O'Connell, Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of the rental registration in
accordance with Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements.
Observed leaking roof within kitchen area.
You are directed to correct the violations listed above within twenty-four(24) hours
of your receipt of this notice by pulling pertinent building permit and repairing leak
so it does not leak into kitchen.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations,please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
Q:\Order letters\Housing violations\Rental ordinance\69 South Main Street Apt.-2.doc
PER ORDER OF THE BOARD OF HEALTH
A. Vean .S., C
Director of Public Health
Town of Barnstable
Cc: Timothy O'Connell,Health Inspector
Wolfgang Schutzinger, Tenant
Q:\Order letters\Housing violations\Rental ordinance\69 South Main Street Apt.2.doc
LA1,
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FORM 30.FC�w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H ALTH
CITY/TOWN
w
i
D�DEPARTMENT �
ADDRESS
GSM Sv9
p� TELEPIAONE o
Address Occupan
Floor Apartment No. No. of Occupants
No.of Habitable Rooms o.gieeping Rooms-__
No.dwelling or rooming units_ No.S ties 1
Name and address of owner
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:
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. 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.:
Stagks, Flues,Vent , feties:
Kitchen Facilities in I -2-
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 V101 ATIOdd 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 SIGNED AND CERTIFIED UNDER E PAINS AND
PENALTIES OF PERJURY."
INSPECTOR_ TITLE l
AA
DATE Cl TIME
C-7,�� A.M.
THE NEXT SCHEDULED REINSPECTION 1, P.M.
Y�
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410,620 state minimum requirements of fitness for
.human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105,CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
1 (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.
ti
COMPLETE
■ Complete items 1,2,and 3.Also complete A. Sic nature
item 4 if Restricted Delivery is desired. /';� &X� -- ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. R ceived by(Printed Name) C. Date of Deli ery
■ Attach this card to the back of the mailpiece,
el or on the front if space permits. U ��5 d 7
D. Is delive address different from item 1? ❑Yes
1. Article Addressed tonn If YES,enter delivery address below: ❑ No
I
PA6 6 2 V IC S 3. Service Type
V AJ�IA. 2 Certified Mail ❑ Express Mail
❑ Registered W Return Receipt for Merchandise
❑ Insured Mail Cl C.O.D. 1
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(Transfer from service label) 70051160 x 0000 0191 2 4
PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540
Ali i it
V n.
UNITED STATES POSTAL SERVICE
e aid
tEIM"
.10 ��MhVttL
iMl:�:"m5 r 1Q,�
9
jwl
• Sender: Please print your name, address, and i " in this box '
i
Town of Barnstable
Health Division _(1�
200 Main Street
Hyannis,MA 02601 C
Certified Mail#7005 1160 0000 0191 2427
P�OFTHE ropy Town of Barnstable
Regulatory Services
9�BARNSTABLE, e
MASS. 04 Thomas F. Geiler,Director
Opp .639. �`$ D _C�
TEb MAt Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
May 14, 2007
Richard Callahan
770A Main Street
Osterville, MA 02655
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 69 South Main Street Apt. #2, was inspected
on May 3, 2007 by Timothy O'Connell, Health Inspector for the Town of Barnstable.
This inspection was conducted on the basis of the rental registration in accor ance th
f�arn-st o e. '
The following violations of the State Sanitary Code were observed:
105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements.
Observed leaking chimney in kitchen area.
105 CMR 410.550 (B) -Extermination of Insects, Rodents and Skunks. Infestation
of winged insects in bedroom; insects believed to be termites.
You are directed to correct the violations listed above within twenty-four (24) hours
of your receipt of this notice by exterminating all insects in bedroom and correcting
source of infestation. You are directed to correct the violations listed above within
thirty (30) days of your receipt of this notice by fixing leaking chimney.
Q:\Order letters\Housing violations\Rental ordinance\69 South Main Street Apt.2.doc
You may request a hearing before the Board of Health if written petition requesting same
Y q g P q g
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine.of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF THE BOARD OF HEALTH
Th as A. McKean, R.S., C
Director of Public Health
Town of Barnstable
Cc: Timothy O'Connell, Health Inspector
Wolfgang Schutzinger, Tenant
Q:\Order letters\Housing violations\Rental ordinance\69 South Main Street Apt.2.doc
Certified Mail#0000 0000 0000 0000 0000
.:t
4 O r � Town Of Barnstable
. �' Regulatory Services
x TiefFL�i5Te1Sl;; �
Thomas F. Geiler, Director
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
date
70 (A) named`
city,state,zip
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY
CODE H —MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at (01 5d �^' � �" was inspected
5 e� (Address)
on_/_/ by I , Health Inspector for the Town
(date) (Inspector's n e)
of Barnstable,
(Reason for inspection)
The following violation(s) of the State Sanitary Code were observed:
State code violation number-violation escri do
105 CMR 410.
Z rtrwvu�
105 CMR 410. '�,Vb
105 CMR 410.
105 CMR 410.
Q:\Order letters\Housing violations\Rental ordinance\template.doc
105 CMR 410.
The following violation($) .of the Town of Barnstable Code were observed:
(Town code violation number-violation descri tion) .
§170-_ -
§170-_-
You are directed to correct the violations listed above within ( )
� (#) �
of your receipt of this notice by (written#)
✓ �
M
fi
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., CHO
Director of Public Health
Town ofBarnstable
Cc:
(Name,tenant,owner,Fire De t.,Building Dept....)
Cc:
(Health inspector's name)
(Generic codes located at QAOrder letters\Housing violations\Rental Ordinance\GENERIC CODES.DOC)
QAOrder letters\Housing violations\Rental ordinance\template.doc
z i
Certified Mail#7006 0810 0000 3524 9483
�oFIKE rows Town of Barnstable
Regulatory Services
�x BARNSTABLE.
\9 MASS. Thomas F. Geiler,Director
ap s639• ��
ArF°MAC' Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
April 18, 2007
Richard Callahan
770A Main Street
Osterville, MA 02655
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 69 South Main Street #2 Centerville, was
inspected on April 5, 2007 by Timothy O'Connell, Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of the rental registration 'n
acaorclariCe It C' 1711 -,rtLe Tnixm ofRarnetal�lr> rude S
The following violations of the State Sanitary Code were observed:
105 CMR 410.482— Smoke Detectors. Inoperable smoke detector.
105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements. Door
off kitchen area(side door)has rotten base and threshold;preshold at front door not
securef indow in kitchen that cannot be opened;f'window in bedroom leaks no rodent
proof cap on chimney and tenant stated there may be a raccoon problem.
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.You are
directed to correct the violations listed above within thirty (30) days of your receipt
of this notice by replacing slider door and casing (threshold); by fixing or replacing
windows in kitchen and in bedroom; by making chimney rodent-proof.
*Note: COMM Fire Department has been notified that there was an inoperable
smoke detector at the time of inspection.
QAOrder letters\Housing violations\Rental ordinance\69 South Main Street Apt.2.doc
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF THE OARD OF HEALTH
o a c ean, R.S., CHO
Director of Public Health
Town of Barnstable
Cc: Wolfgang Schutzinger, Tenant
Cc: Timothy O'Connell, Health Inspector
QAOrder letters\Housing violations\Rental ordinance\69 South Main Street Apt.2.doe
Certified Mail#0000 0000 0000 0000 0000
Town of Barnstable
Regulatory Services
RNA
Thomas F. Oeiler, Director
Public Health IVSO
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
date
�S*A ss M A
city,state,zip
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.
D �-The property owned by you located at 6� ��>� � was inspected
O� \ (Address)
on_/_/ by (J , Health Inspector for the Town
(date) (Inspector's n ea�
of Barnstable,
(Reason for inspection)
The following violation(s) of the State Sanitary Code were observed:
State code violation number-violation description)i
105 CMR 410. '500 -
bell- NJ
(A_ eolip UVI- -
J
Q:\Order letters\Housing violations\Rental ordinance\temp late.doc
117 k
s l • ��--- ��- `—�
105 CMR 410.
The following violation(s).of the Town of Barnstable Code were observed:
(Town code violation number-violation description)
§170-_ -
§170-_ -
You are directed to correct the violations listed above within
_ ( )Sys..
of your receipt of this notice by r `, (written#) W v
°�` `ti
T_ £
yn
UL
e
You may request a hearing before the Board of Health if written petition requesting sa me
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
Cc:
(Name,tenant,owner,Fir ept.,Building Dept....)
Cc: 1 C�
(Health inspector's name)
(Generic codes located at QAOrder letters\Housing violations\Rental Ordinance\GENERIC CODES.DOC)
Q:\Order Ietters\Housing violations\Rental ordinance\template.doc
r FORM30 IIW HOBBSBWARREN n THE COMMONWEALTH OF MASSACHUSETTS
�_�
BOARD OF W- T H
CIT��\
W
DEPAR ENT _ M
ADDRESS �—
TELEPHOL4E
Address _ ---Occupant---. U
Floor Apartment Na Ca-,____- No.of Occupants_
No.of Habitable Rooms No.Sleeping Rooms_________—
No. dwelling or rooming units_ ___ No.Storie
Name and address of owner
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches: Kh
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows: 1 S�
Roof (—
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall, Ceiling: VW
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. 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 I Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.:
S_ta.Qks, Flue Ve feties:
Kitchen Facilities ink
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 REPORTA SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY."
INSPECTOR S _ TITLE_
jj� ----
DATE " I TIME_____��
THE NEXT SCHEDULED REINSPECTION � � P.M.
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410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1) and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
----- -(P) -Any-other violation of 105 CMR 410.000 not enumerated in 105 CMR-410.750(A)through (0)-shall-be deemed to be'a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
I
Town of Barnstable
o� Regulatory Services
SA.RNSPABM Thomas F. Geiler,Director
9� 1639. A Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
April 5, 2007
Attn: COMM Fire
Health Inspector Timothy B. O'Connell conducted a rental inspection in accordance with
Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary
Code, 105 CMR 410.482, the Health Department is required to notify the Fire
Department if there is a smoke detector violation, or possible smoke detector violation.
The following property had possible smoke detector(and\or CO detector)violation(s):
69 South Main Centerville, Assessors Map-Parcel: (228-125):
-Smoke detector within apartment not working.
0
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Timoth O'Connell-Health Inspector
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Developer
Parcel ID 228-125
Lot
Location ?69 SOUTH MAIN STREET Pri Frontage 170
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Owner Info
owner CALLAHAN, RICHARD P & Co-owner[HOSTETTER, PRICILLA M
Streeti 345 SEASPRAY AVENUE Street2
City(PALM BEACH -� StateFL Zip33480 Country US
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{ Acres 10.53 Use 4-8 Units MDL-94 Zoning RC Nghbd 0108 t
Topography;Level Road Paved
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Construction Info
Building 1 of 1
Year1900 _.._. -_._.._...._.. SRuoY#__ w
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Model Commercial Int�,ardwood Bath 14 Full
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Permit History
Issue Date Purpose Permit# Amount Insp Date Comments
Visit History
Date Who Purpose
10/12/2001 12:00:00 AM Paul Talbot Meas/Est
- Sales History
Line Sale Date Owner Book/Page Sale P
1 1/15/1994 CALLAHAN, RICHARD P & 8990/075
2 6/15/1993 BBX REAL ESTATE CORP 8614/140
3 2/15/1985 SAURO, DAVID A 4406/193
Assessment History
Save# Year Building Value XF Value OB Value Land Value Total Parc(
1 2007 $238,700 $4,600 $0 $232,500
2 2006 $260,700 $4,600 $0 $220,900
3 2005 $248,500 $4,600 $0 $203,200
4 2004 $124,800 $4,600 $0 $169,300
5 2003 $186,800 $4,600 $0 $68,900
6 2002 $183,200 $4,800 $0 $68,900
7 2001 $183,200 $5,100 $0 $68,900
8 2000 $143,500 $5,000 $0 $38,400
9 1999 $143,500 $5,000 $0 $38,400
10 1998 $143,500 $5,000 $0 $38,400
11 1997 $155,900 $0 $0 $30,700
12 1996 $155,900 $0 $0 $30,700
13 1995 $155,900 $0 $0 $30,700
14 1994 $141,500 $0 $0 $34,600
15 1993 $141,500 $0 $0 $34,600
16 1992 $160,900 $0 $0 $38,400
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VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. T c.' 'A)
SEPTIC TANK CAPACITY L v
LEACHING FACILrFY: (type) .L ell / (size) A-,) gO
NO.OF BEDROOMS LI
BUTT-DER OR OWNER . ✓%�, , .l.f ! .��1,.•�n�A i
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
i
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ='!J Feet
Private Water Supply Well and.Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
`°Edge of /eEland`and Lea'hin'gFacility(If any wetlands exist
within 300 feet of leaching facility) Feet
.Furnished by {"
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Fss..... lI-.l!1.1....
THE COMMONWEALTH OF MASSACHUSETTS
OAR OF HEALT
.................).�a�....0F. ) . . ..r
ApplirFation for Dhipoii al Workii Tomitrurtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...............[ +.. -------- - ---
Location- s or No.
•--••-.......cha --- - ...:.:.�)d :'........... G U. ,� ......... ........... -.......--
ar. ?..... ---.-- ......................................
Installer ddress
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
114 Other—T e of Building No. ofpersons_------------------------- Showers — Cafeteria
a' Other fixtures ..................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length----------_--- Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----_------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1-__-_-_______-minutes per inch Depth of Test Pit.................... Depth to ground water........................
(% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
} )
O Description of Soil----------------------.c��'• � l - -- - - - -.....
x /
U ----------------
-------
----------------------------------------------------------------------------------------------------------------------------------------------------
.....
-------------------------- ------------------------------------------------------------------------------------�--L--------------------------
U Nature of Repairs or Alterations—Answer when applicable.____/j;. V&.- a1...._.. .. ..................................
.....................•..._...........................---....---._...._...--..--••-------...._.._........._.. - - )_. •-- )--ram•-------_..-_--------.-----__.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersi ned further agr s not to place the system in
operation until a Certificate of Compliance has bee ssued by t e a of health.
nn
Signed...... . . -- -------- • • •. •......... P� .-
y / Date
Application Approved BY............................ ••-•....... .... ............................. yf�
Date
Application Disapproved for the following reasons_.....................................................______________________-------•-- •-•---,
--------------------------------•-----.....-----....----•-------••----.........---------------------•--....--••-••-----•---•-
PermitNo.........................................................
No...., ..��1 r� a FEs.._....1 _..r r
THE COMMONWEALTH OF MASSACHUSETTS
----___BOARD OF HEALTH
. ..... j-..........OF.....t....... `
Appliration for Diipooal Workii Ton rurtion •amit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at•
JJ
... ....................................................................... ......._____._.........__.........__.........._._..._.........._._....._...._.._...__.._...._..__.
Location-.Address°'� _ _ or Lot No.
......- 1 ..............................................! ._1 ...---- ...---__- • -------- .•
---- _.__..... �_......._..... ......._....
r J Owner / -�' f/ Address
Installer Address
Type of Building Size Lot............................Sq. feet
F., Dwelling'—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( )
Otherfixtures .---....----•-•-•-------•-----------•-----------------••--••--•-•--•------•-------------------••--•--•_._...•-------------•---•---•-------.......----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter..._____________ Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I________________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
W ----•------•------------------------------------•--------•-•---------------------------=----------------•------------------------------•-------•--••-•-•-•---•---•••-----------••---•--•.............
UNature of Repairs or Alterations—Answer when applicable------------:...................... --_______ ......... ....................................
. /, /
Agreement: /
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board'of health.
Signed_. _.., ` ', /f.7:1�/ J............................................... -l f - .:
�J Date
Application Approved By.............. >... %J ........................ / ..-- C/
Date
Application Disapproved for the following reasons:----------•-----•--------------------------------------------------------------------------------------------•--
--------------•--•-•...._..•-----------......•----•--••------••-----•-•---•--•--•--....----•--------••.....-•--•--------•------------------••---•--•--•-••------•-------••-----------•--•-----------.._.
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
!........'...'...................OF..........�.......................................................................
Trr#ifiratr of Tontplionrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
i Installer
-_,_
/ .... i r 7 1 . / . / ✓
has been installed in accordance with the provisions of TIT 5 of Tye State Sanitary Code as described in the
application for Disposal Works Construction Permit No............A.! ---••--- dated-..............................................
THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WI��.F CTION SATISFACTORY.
DATE....... ._��..--••........................•--•-••--..._....._..._. Inspector........ --•- ---•-------•------------------------•-----•----•-•••......•-••-•--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF........... / , ) )- 1�/ //
G/ » ................,,..._._.......------..:_............._..._............_..
FEE.. l/ l
No...................��� __......_..............i
�io�roo�tt orko �ono�rttr�ion •eruti� -
Permission is hereby granted.................
;....._....... = = t...._
to Construct ( ) or Repair (i ) an Individual Sewage:Disposal System -s--
atNo............J--^-rf. f_........--1--...........J J •-f-•---! / r f
, r
Street
as shown on the application for Disposal Works Construction Permit No..................... Dayd..........................................
--- _ =-- >-- ------------------------------------------
a of Health
DATE --------•----•---, ._r .
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS