HomeMy WebLinkAbout0035 SEABURY LANE - Health 35 Seabury Lane, Centerville
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J4RECVc(fpCo
UPC 12543
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No..53�.. LOR ��2'n•co ����
HASTINGS, MN
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"GOWN OF BARNSTABLE
LOCATION�� ��� SEWAGE # �.
VILLAGE M�,AA ASSESSOR'S MAP-& LOT 2 ^
1"�F-Q kb
INSTALLER'S NAME & PHONE NO., 737, P
SEPTIC TANK CAP 4CIFY 1 (5 C) o
LEACHING FACILITY:(type)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER "
BUILDER OR OWNER� b _�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED;�`�_�-���,
VARIANCE GRANTED: Yes NO
/ r a
3� 4
No. f Fps.. ....2�....4.Q._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.........`r o wn... ..............0 F............Barns-table.............................................
Application is hereby made for a Permit to Construct ( ) or Repair ]kX) an Individual Sewage Disposal
System at:
................35 Sea_b__urv.Lane Centerville,Mass
_.. --•---...-•--------------------------------• -•------•-•-•-•-----------••-----•---•------•-----•--------•--------•-......----------------••---
Location-Address or Lot No.
....... eorge_.?`�I��GI1Yl�!....................•-•------------...-•----•--• -•-- .................................................................................................
Owner Address
J.P.Macomber Jr.
Installer Address
UType of Building Size Lot------------------_-------Sq. feet
DwellingX—No. of Bedrooms............a.............................Expansion Attic ( ) Garbage Grinder ( )
aOther Other—Type of Building ............................ No. of persons....._......._....__._...... Showers ( ) — Cafeteria 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 ( )
W Percolation Test Results Performed by---------------------------
-----------------------------
•---------------- Date....................................
Test 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........................
a --------•--•---••---•-------•--•••••-•••...•--•-••....--•-----•---••-••---...-••-----•-._.....••-•----•---••-•••...-•-•---•••------••......•-•-•----•-••-----
0 Description of Soil................................................................
=
------•-------•-----
Sand & Gravel
W
-------------------•--------------••---------...-----------•-•-----------••-----•------•--••---•-•-•----•----•-•---------••-------......---••-•----•-----••---------•--•---••---------•-----••--•-•---•-
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------•-----------------•------•---------------------------------------------------•---•------•----------1-1-Q-Q_Q--�al�..Qn.._tan_k�..._1.-1.0.Q.0..Pit.......--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'T 11..E 5 of the State Sanitary Code— The undersigned further agr es not to place the system in
operation until a Certificate of Compliance has b n issued t �doflt
Si ne 5/23/89
g '-----------•.. ..••...........................
Date
ApplicationApproved By............................ . -••--...•---....••----•-------------•-••----•-......---•-•----•-. .........................................
Date
Application Disapproved for the following reasons---------------•-------------•-------------------------•-----------------------------------...._---•--••---..__..
--------------------•.........------------......------............---•--------•------------•----------.....--------...-----------•------------------------------.....----------------------------•-•-----
Permit No._ `•.. J..`�------------------------ Issued._ '. -U t Date
O
No: l S FsS..........................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF • - 1• .
ApplirFation for Uhipos al Works Tomtrnrtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair 'O an Individual Sewage Disposal
Systemat ...... ---•----••.---- ••--- . --.-•-- .. _...... ..... ............ ..
Location-Address or Lot No.
Y Ea i'Illj ;)�
Owner Address
-------. --------
,-a
� Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling=No. of Bedrooms............ .............................. Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons-------------------_-------- Showers — Cafeteria
P 1 Other fixtures ..---•--•---------------- ......-----------------•---
W Design Flow............................................gallons per person per day. Total daily 'low............................................gallons.
R: Septic Tank—Liquid'capacity----___-____gallons Length................ Width................ Diameter_............. Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------- -----------------------------•---------------- Date........................................
W
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water,_____________-_-___-___.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W ---•--------------------------------------------------------------------•-•-..-----•---------------------------------------------------------------
----------
0 Description of Soil..........................................................................•-------------------------------------------------------------------•------------------. ----
"W Sand & ryr iv,
V ---•--•------•----•------------------•---------------•-•--••---......-•--..---
W
VNature of Repairs or Alterations—Answer when applicable................................................................................:..............
1 1 ,000
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iT`:IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be/en issued by the board of healtthl
Signed:., t .� r .... �l t✓ ...............*e... ...�„�....
ApplicationApproved By--••--•••-•------•---•-... •-----------------------•-----•. --...............• D-t-•-•............
Date
Application Disapproved for the following reasons:.............................................................-----------------------------•-•-•------------•----
-------------•---------------••-•- --•-.--------------------------•------------------ ------.
" ,. Date
PermitNo......................................................... Issued.............. ------------------------•---------------
D'_..
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF................. ...............................................:.................
CIrrtifiratr of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired '( )
by....... = = = • .........................................__= ..................................................................................................
-,i•,a t^•3. T ''> n ---. Installer
7 -
at -------- -----------•----••------•-----------------•-------- ---•-----------------
has been installed in accordance with the provisions of TI rL' 5 of The State Sanitary Coe as described in the
application for Disposal Works Construction Permit �ro---J _"�;5��---- ......... dated_..j f.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A 4UARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................ .-7_ ....................... Inspector...---------- ......................................................
THE COMMONWEALTH OF MASSACHUSETTS
IN-
BOARD OF HEALTH
Z- '-
T`c�s•�n...................OF.. .T31arnst abbe f` �(3
NO... FEE.............•..........
Disposal sal nrkii Tiftudrudiou rrmit
J. '..Ma(-ombcr Jr.
Permission is hereby grax .. .....................................L
to Construct-( ) _or RepairIndividu ewage Disposal System
. 7
. ' .............
//6
as shown on the application for Disposal Works Construction Pe Dated.:___,__.✓.::::::............................
s . --Board otHealEli•_l�.
-
DATE------------------------•----------•--...---••--------••-----•-••----•-..._..... ..._ t ,
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS '
Commor►weOtth of Mossochusetts John Grad
Executive OMCe of ErMrorvr ientol Affcdrs D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
Teaticket,MA 02536
D Environmental Prote�tgon (508) 564-6813
% 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F 1*
PART A DLO CERTIFICATION
35 Seabury Lane Centerville Address of Owner: FES 18 1997 Q
Property Address. (If different) `
Date of Inspection:2110197
Mead P
Name of inspector:John Gracl OEPT.
V
Company Name,Address and Telephone Number:
J ,
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X P8SS85 This inspection is based on criteria defined in Title V
code 310 CMR 15.303.My findings are of how the system is
_ Conditionally Passes performing at the time of the Inspection.MV Inspection does
Needs Further Evaluation By the Local Approving Authority snot eptic system and any of Its any warranty or ucrantee f components life.
of the
Fails j
Inspector's Signature: Date: 2113197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
Check A, B,C,or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as 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 completion
of the replacement or repair,passes inspection.
Indicate yes, no,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 exfiltration,or tank failure is
imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
• 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Seabury Lane Centerville
Owner: Mead
Date of Inspection:2110197
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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.
ER SUPPLIER, IF
2) TSYSTEM HAT WILL
FUNCTIONING pIN A MANNER THAT PROTECT THEPUBLIC HEALTH AND SAFETY MINES
AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone 1 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 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
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 in facility or system component due to an 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
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 seabury Lane Centerville
Owner: Mead
Date of Inspection:2110197
D] SYSTEM FAILS(continued)
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
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 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. 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 large systems in addition to the criteria:
_ The system serves a facility with a design flow of 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)
shallThe owner or operator of any such system system
rounwatr
re u ements of 314 CMR 5 00 and 6.00. P ease consu t thelocal regiona f l office of compliancefurtherg
f the Department for information. program
4
(revised 11115195)
3
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 35 Seabury Lane Centerville
Owner: Mead
Date of Inspection:2J10197
Check if the following have been done:
X Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the 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.
Ma As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or Industrial waste flow.
X The site was Inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the Interior of the septic tank was Inspected
for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115/95)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 35 Seabury Lane Centerville
Owner: Mead
Date of Inspection:2110197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 2
Number of current residents: 1
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: nla
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: Na
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: Na
OTHER: (Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last two years.
System pumped as part of inspection:(yes or no)Yes
if yes,volume pumped: 1000 gallons
Reason for pumping: Maintenance.
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
News stem Installed In 1989.
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Seabury Lane Centerville
Owner: Mead
Date of Inspection:u10197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: TV
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'8'H 5'7"W 4'10-
Sludge depth:3'
Distance from top of sludge to bottom of outlet tee or baffle: 24'
Scum thickness:7'
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: 11'
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.)
Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete,_metal_FRP_other(explain)
Dimensions: nla
Scum thickness:Na
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle:nla
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.)
nla
(revised 11115195)
6
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Seabury Lane Centerville
Owner: Mead
Date of Inspection:2110197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
n1a
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: Liquid level with bottom of pipe.
Comments:
(note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.)
Distribution box is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n1a
(revised 11115195)
7
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Seabury Lane Centerville
Owner: Mead
Date of Inspection:2110/97
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
n1a
Type:
leaching pits,number: 1 leach pit
leaching chambers,number:nla
leaching galleries,number: nfa
leaching trenches,number, length: nfa
leaching fields,number,dimensions:nfa
overflow cesspool,number:nfa
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The sas is runctioning property and is sturcturally sound.
CESSPOOLS:
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert: nfa
Depth of solids layer: nfa
Depth of scum layer: nfa
Dimensions of cesspool: nfa
Materials of construction: nfa
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
Na
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: nla Dimensions: nfa
Depth of solids: n►a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nfa
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Seabury Lane Centerville
Owner: Mead
Date of Inspection:2110197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
A
� o
c
a
Rc i,
DEPTH TO GROUNDWATER
Depth to groundwater:72 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
Z Uj
3 �P
Proposed Addition
for Patricia Kennedy
35 Seabury Lane
Centerville, Massachusetts
Design by Hilton Abbott
November, 2003.
GROUND LEVEL PLAN
• I
I. 14'
I I
14'� 14' - I�* 9 4 6 -�I a a a
u, 1 II\ 1 11 I
a
flat ceiling -d 15 North
23 `` �
\ -d
wash]
1 11
�
21-4 J
shower OO 0O f N—5'—0,1.4 8'-711-1
e a
i
F
owerrefrig Pantry fire place =-� i
4
C__ pocket door
� vaulted ceiling W
I �JI flat ceiling 15'
c-- archway.. ...a 16'
o vaulted ceiling """" """"' """'
C-- EXISTING
EXISTING STRUCTURE
collar ties `
00 .. ST RI;ICTURE
,
closet
matching window I j
reused from west side I i
I, 1 -I 24'
5'
Scale: 1 inch=6 feet
BASEMENT PLAN
retaining wall
. i
— 14' i 14'
I I f Existing grade
I
I a a — —
I I
a--
enclosed
13' a--
stairs 15'
retaining wall a--
21 1-4„
f
Existing grade `
i
cement block support ll
I
for fireplace above
15' EXISTING STRUCTURE ; 16'
f �
I
24' �—
Scale: 1 inch =6 feet
FOUNDATION PLAN
14'
North
2"x 10"joists
'~-16"oc with bridging
FT I
2"x 10"joists
16"oc with bridging 15'
13' triple 2 x 10's
above beam
Girder
four 2 x 10's
,
4-1 21'-4"
........... ..
3' x 3' x 10" pads, 5 x 10' x 10"pad
and lally columns: for fireplace & columns
t �
4
15' 2"x 10"joists double 2 x 10's EXISTING STRUCTURE ; I
12"oc with bridging
yl
Scale: 1 inch=6 feet
Exterior Mill Work Schedule
Windows: Anderson
a) TW2432 30" x 41" double hung
b) TW24410 30" x 60" double hung
c) C13 2'w x 3'h casement
d) ARV251 28" w x 17" h awning
e) ARV31 36" w x 17" h awning
Doors: Anderson
f) FWG 5468L 5'w x 6' 8"h left open
g) FWG 6068L 6'w x 6' 8"h left open
h) FW 3168 3'w x 6' 8" h hinge right
WEST SECTION
2"x 10"rafters
16"OC
IS INW
ST I'UT YL I ZE A,
'A UUUUU U
2"x 6"studs
' 'OC
_ 9b
2"x 10"joists
ERR 11 MiTii tvii I
16"OC with bridgh
111 11 H T1 11 11 H H 11 n H I] I] H H
2"x 10"joists
16"OC with bridging
header for slider 81
three 2 x 8's retaining wall
8"wide
2"x 6"studs
24"OC 3'
LLLLLL _ ................ i.....
concrete foundation 31
& retaining wall
8"wide _
concrete foundation
frost footing 8"wide
1'hx2' w
Scale: 1 inch =6 feet
SOUTH SECTION
ridge vent _+
asphalt shingles_y
R30 insulation
with vapor barrier 4 x 8 collar ties
soffit vent &2 x 10 joists
0.5"sheathing
&white cedar shingles �
2"x 6"studs
R19 insulation
'oc
/4"plywood
0.5"sheet rock
Ll 2"x 10"joists
12"oc with bridging
_�-- spruce shoe
P.T. sill
9, 8' sill seal
* 8"poured concrete
3' foundation
1'x 2'footings
Scale: 1 inch =6 feet
EAST ELEVATION
f�Fr f F fr;%�'/ //� f /+ rf f F� `r., � F` f• �+
!{f+�/, r''Ff> fr /F ++{ F} ri� :+ sf •{,J'r�''�,••'s r'trf �/'� •,.' f{ 'fF }'{ r f+.
i'F` f,.f ,�` {frir F+•'/r+ ,fr,'F'{:fir.{{f }` /:Ff r/,�/.Fjr } f f r ,r: F /� ;''': /' •�'/'�?'�'rf f
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NORTH ELEVATION
EXISTING
STRUCTURE
v,orosoa Addition
EXISTING
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° s� BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT
SUPERIOR COURT HOUSE
"•'— r BARNSTABLE, MASSACHUSETTS 02630
PHONE: 362-2511
X1 A 5 7 EXT. 330
LAS 3?7
CLINIC 340
.Dear Roberta Go49h ,
4/10/97
Oil 4/2/97 an inspection was held at the
address below for the detection or lead-based I)aint . 11i
accordance with Hassachusetts Geiieral Law Chapter 111 ,
sec . 190-199 , any lead paint detected in a residence where
a child under six years of aye resides must be removed .
Based on the inspection , the followiny apply :
Lhe premises are lead-free
X lead-based paiiiL was deLected , hut•,evr? r ► nu children
under six years of aye presently reside in this
dwelling
lead-lased paiiit v,;is mid healLh
Hazard to Lhe children res idilry Lherci ll
lead-)lased paiiiL was detecL" ed F"'d ;i hr-n 1 Lh
Hazard to children aLLendiny daycare/preschuol
therein
insvectiuii, required Fur szi 1e OI lei (,l �r•i l
inspection required Cur permit
final iiispecLiuii - violaLiulls iiuLed
have been correcL-ed
Location of Property ner
r35 Seaburry Rd. c/o/Roberta Gough
Centerville, MA P.O. Box 464
Centerville, MA 02632
Please coiitacL Lhi s uL r i (_e should )-oti i -qu i i r ;liiy• LurL"her
iiif-orniati.on regardiny this matter .
Respect f li 1 1 y• ,
CV 7—C
Pu lac Healt sanitar ' n
f
r
Barnstable Count,Lq,tgdjnspection/ Surface Assessment Form
Environmental Department
Superior Court House
InspeOWif1M9abEer, MA 02630 Page / of�_
Meth Used: 7
p(� IVN expiration date_
License# C l •1 L�JC-Kay Fluorescence
Model <�erial#
Address Apt.# City
Child's Name(Last,First,Init.) Birthdate (NUD/Y) Sex
Parent/Guardian's Last Name Parent/Guardian's First Name
Single Family
Owner's Name: Multi-Family ❑
Owner's Address: Number of Units —
KEY: CAP capped Remarks/Calibration: - r
COV covered
DIP dipped ��� 'V!
ENC encapsulated
MI' made int.Ct o/t e e F/
NA not accessible
NEG negative Scales:(scores of 0 or 1 pass,scores of 2 fail):
PCs posntve
PRE prepared Surface/Subsurface 0.no paint'all paint intact 1=<10%pant not intact 2=>10%paint not intact
REM removed Substrate 0=intact 1=<10%needs repair 2=>10%needs repair
REP replacementInitial est 0 i=no pant remwed 1=<1/16'paint removed 2=>t/16' aint removed
REV reversverseddl T T
Pal P
SCR scraped to bare substrate X-Cut Tape Test 0=no paint removed i=<1/16•paint removed 2=>1/16-paint removed
/•S /•3 /. /.� /.s1. 7 IS /.
Floor# / C• 0 LjU -C-/ G"11oor O_I O.Y--per O.z-
-I- -1- -1- -I- -1- ,- J,C1 - 1 - 1 - L - L -L -1- - -I- -I- -I- -1- -1- J- JC1 -1 - 1 - L - L -L -1- -
I I I 1 I I I I I I 1 1 I I I I I 1 I I I I I I I I I 1
_ -Y - t - t - t" -t—r - -r' -I- -I- -I- -I- y- '1 --t - _r t - t -
_
-F- -I- -I- -I- -I- 1- -1 - -4 - +.- + - + - 1- - F -H - -F- -I- -I- -1- -I- -i- -1 - ? - +- + - +- - 4- -F -F -
I I I I I I I I I I I 1 I I 1 I I I
- -
- - - - - - - - - - -- -- - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - -
?1 I I I I I I I 1 I I I 1 I I I 1 I I i I I I I
_ -4 -I 4I. 4.. 4
.. - t- -1I -1.-I I I -1I- -1I- -1I- -1I- -4I -4I I +I - 1I- I -II -II
-
- 1I - T - T - T - r -r -1 -I - T - T -r - r - - -,-
B D B -
-
L _I- _I__I_ J_ J_ .1 _ 1 _ 1_ 1 _ L _ L _L _LID
-r -I- -I- -,- -1- --A/�, -
T - T• - I- - r-- _ -f -,- -,- -I--I- 1- '1 -Z - ?-T - r - r -r -r-
_ I _ - _ I - _ _ _I_ _I_ _I_ _I_ _I_ _I_
-
I I I I I I 1 I I I I I I i I
I I I I i I I I I I � 1 I I I I I 1 I 1
- -1- -1- -1- -1- -4 -4 - + - I- I- - -1- -1- -1--1- -1-1- - - + - + - + - + - 1- - 1 '1
I I I I I I I I I 1 I I I I I I I I I I I I I I I I I
A(street side) A.(street side)
Pb (lead) more than 1.2 mg/cmz with x-ray fluorescence or positive with Na,2S is Dangerous.
lead zards? t.in compliance
INSP. DATE a (, N ��� REINSP. DATE ____1 3"r one upancyesa
O 3.failed panty .
4.failed
Inspector
compliance 1.In compliance
REINSP. DATE aREINSP.2.work in progress DATE 2.work In progress
3.reoccupancy 3.reoccupancy,
4.failed a.failed
t.In compliance Full Compliance Date
REINSP. DATE ❑ 2.work In progress
3.reoaupenry
4.failed
Inspector
Did you complete a surface assessment for encapsulation? Y or N
EXPLANATION OF LEAD INSPECTION/SURFACE ASSESSMENT REPORT FORM COLUMNS
s »><> >
Refers to A, B,C,or D side of dwelling unit. Refer to diagram on cover sheet.
tions/surfaces are listed in this'i.... <`: Refers to architectural elements being tested. If two loca ste column,
( ) g n, subsequent
> « >`< corresponding to each surface.
columns will be subdivided to provide specific information p g
w with a The actual lea nu at the surface as tested th n XRF d result. A numerical reading indicates that analy
zer yzer and a
readingor avers reading)greater than 1.2 m c r> indicates a dangerous level of lead. A' os'or'n e notation
( 9e 9)� 9� 9 P
9
indicates that the surface was tested with sodium sulfide and a' os'notation indicates a dangerous leve
l of lea
d.
P 9
Each location tested must have an individual dividual result recorded in the'Lead'column.
h
I ><' <<` <><< ''< <` The
loose column indicates the condition of the painted surfaces tested. A check mark or(loose) p ( ) (.� `yes'notation
in this column means one or both of the surfaces tested is not intact. If this column is left bl
ank or has a'no'
no
notation,' m leaded u 6 it means that the surfaces in question is intact. Some e surfaces are'n i i violation regardless of their
( ) q 9
condition;
ti others are in violation only if the paint is not intact.
8 >'>«>=>` The wr abt'(owner abatement)column denotes whether or not a surface in violation can be corrected by a trained
homeowner/agent
I who is not a deleader. A es'in this column means that the trained owner/agent ent may elect
to
�Y Y 9
dl e ead this surface b performing one of the specified low-risk deleadin ac
tivities. A no m this column
means
Y P 9 Pe 9
that onlya licensed deleader i delead surface.
a er s permitted to this s rf ce.
P
The dlr srf prep'(deleader surface preparation)column denotes whether or not a deleader is required to prepare
a surface in advance of it beingdeleaded b a trained homeowner/agent performing certain I s d I
Y P 9
rt ow-n k de leading
9.
activities. A es in this column means that a licensed deleader must be e t used toe o
y
rf rTn surface preparation if the
P P P
low-risk activityselected's encapsulation r v onlm io co enn a friction/impact act surface with loose lead paint.
9 P The 'surface/subsurface" condition column denotes the condition of the paint layers with respect to potential
eligibility for encap
sulation. Surfaces/subsurfaces rated a'2'are ineligible
e for encapsulation.
g h P 9
The'substrate condition'column denotes the condition of the base substrate(i.e.wood,plaster,metal or masonry)
withrespect to potential al eligibility for encapsulation.
sula'on Substrat s rated a are ineligible for encapsulation,
unles
s
the substrate is repaired.e ed.
P
The results of the initial tape test(s)required for encapsulation are recorded in this column. Surfaces receiving a
7 on the initial toe test are ineligible for encapsulation.
P 9 P
>:<:> >>>
X EU ; ...:.:.;.:::::.::::::;;: The results of the optional x-cut tape test(s) performed by the inspector are recorded in this column. Surfaces
receiving a
. .
e 2 on the x�ut tape test are ineligible for encapsulation.
9 P P 9
COMM........:........:.::::.;:.:: The'comments'column is for other observations that may be relevant to the deleading of a particular surface
5::>:>::::; '. The'suitable urf t!#T: ::R,�N �:,._::. for encapsulation'column indicates whether a surface is potentially suitable for encapsulation based
on the results of the inspectors evaluation and any tape testing performed. A' es'indicates that sur
face can
be further evaluated b e n sin r
t X-cut to testing and patch testing; a no' indicates ineligible ible fo Cates that the is in
P
surface
Y 9 P 9, 9
encapsulation.
elead date'coumn indicates the date that the surface was determined to be in full compliance with the Lead
Law.
.L11"I1 `) T#)(f ''''« The'delead method'column indicates the method b which each surface was deleaded o full compliance with the
y t I
Lead Law. Refer to the'key*on the cover page
e for me thodcod es.
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BBrqst� iC A1" Health and LEAD INSPECTION/ Page of
Envlr nmen at LJ epartment SURFACE ASSESSMENT FORM
Address of Inspection: Apt# City
EXTERIOR
SIDE LOCATION/ LEAD L OWR DLR SRF COMMENTS DELEAD DELEAD
SURFACE ABT? PREP? DATE METHOD
Siding n - i
Comerboards
Lowertrim
Upper him 7-
Door Ipes
Door casing/Jamb '
Threshold ) L
Door
CDoor casing/Jamb C�
Threshold
Doer.
Door aglJamb
Il][r�d
DoerGasiaQemb
ThFeskekl
/�
Window sill
AWindow casing
w 4 61 Uy Win sash/Mullions
(t Window sill u =
Window casing
GibL -z Win sash/Mullions
Window sill Inns
QL Window casing
Win sash/Mullions
Window sill &� 4-
Window casing J),A
Win sash/Mullions pa —'
Cellar in units
Cellar in units
Cellar in units
Cellar in units
Fou Ation
Bulkhead
Fenees-
C S h Wrt
•h -
to c IA CA
LICENSE p �`�Z DATE
SI AT RE