The URL can be used to link to this page

Home My WebLink About0432 SKUNKNET ROAD - Health 432 Skunknet Road, Centerville �� p.ECYCIpp nIGWW� =J� COyF UPC 12543 Now R •o��si.CO�`J��o- HASTINGS. MN d �/ TOWN OF BARNSTABLE LOCATION y3a S SEWAGE VILLAGE C h ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) l '. (size) 6 XC NO.OF BEDROOMS BUILDER OR OWNER C.& PERMITDATE: COMPLIANCE DATE: SA/ 2 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility O Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by7::::L l/i Aw r hG' 47Z' �, f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 432 Skunknet Rd Property Address r James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 - page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information S/# 15 0 t b on the computer, Mathieu Rebello use only the tab key to move your Name of Inspector cursor-do not N/A use the return Company Name key. Norse Rd Co � Company Address S. Dennis MA 02660 Cityrrown State Zip Code 774-722-0271 SI-14140 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10/24/20 Inspector's Signature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is Centerville MA 02632 10/24/20 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/WO18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts u�= - I� Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.712 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant approx. 3 years t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: NIA Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe below): NIA 3. Pumping Records: . Source of information: last pump within 3 years per owner Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.6' feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints tight,proper venting, no evidence of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon tank Sludge depth: 0-1" Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): the liquid level is equal with the outlet invert with no sign of backup or Ieakage.Tee's in place. Septic tank did not appear to be in need of pumping at this time t5insp.doc rev.7P26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: N/A p gallons Design Flow: N/A gallons per day t5insp.doc•rev.7/26/2018 Title 5 Of vial Inspection Form:Subsurface.Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form cp� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): D-box not present. pvc pipe leaving outlet to leach pit was inspected with camera, pipe found solid with no leaks or obstructions t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form !- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): N/A If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: N/A Type: ® leaching pits number: 1-6x6 pit w/stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): soil and stone appears to be clean and dry. No sign of hyrdaulic failure, 0"of ponding found at bottom of SAS no high stain marks indicating overloading 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is required for every Centerville MA 02632 10/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is Centerville MA 02632 10/24/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 n00,;vCwOk lv A k r � Q 0 l ,O 0 3 +o g fo a _ 30, 6 a a'9 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Pre 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner owners Name information is required for every Centerville MA 02632 10/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15+ 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: preformed hang auger to depth of 15'with no groundwater encountered. Bottom of SAS 8' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts t- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 432 Skunknet Rd Property Address James Giannelli P O Box 148 Centerville, MA 02632 Owner Owner's Name information is Centerville MA 02632 10/24/20 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Z 548 659 942 Receipt for Certified Mail No Insurance Coverage Provided POST TATE, Do not use for International Mail See Reverse► OMf Sent _ St a and lC � P. ate and Z Code C 0 Postage CIDV Z E- Certified Fee L O u' Special Delivery Fee R�St"rteted3D`elNeaylPee� R�ttith R-kc-OipTtShowing7 to Whom&Date Delivered Return Receipt Showing to Whom, Date,and Addressee's Address TOTAL_Postage &fees Postmark or Date STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). m 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address Lo leaving the"receipt attached and present the article at a post office service window or hand it to your rural carrier(no extra charge). CC I 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return Cl) address of'the article,date,detach and retain the receipt,and mail the article. ` L 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. 0 00 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, M endorse RESTRICTED DELIVERY on the front of the article. E 0 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If U. return receipt is requested,check the applicable blocks in item 1 of Form 3811. 0 tL 6. Save this receipt and present it if you make inquiry. to5so3-93-B-0218 public Health Division '(own of Barnstable P mm P BOX 534 Hyannis,.O. 02601 �a t��:oEc? Massachusetts y _ t =s-- 6138443 ` ,r�,�,,��;�RFC"► � EQ�ES� �►�� ° LOUIS PIAZZA 11 CARVER LANE P4iUkryE� 6U NCCAC 1LINCLAIMM;-A. 12 -2-q a cszica m► ] IIJII oil JE1[F1 Iffill„81h.I.,hIi ,I,EIl;I1 i Ii c , Town of BarnstableCERTIFIED -- Department of Health,Safety,and Environmental Services Public Health Division cu, FIV 367 Main Street Z_. 348 659 942 : ti HyannLc,MA 02601 27 F)v v, NOV i ®! �39E 15 a� f �.�/ A Z RETURN RECEIPT RR " 6138443 LOUIS PIAZZA 11 CENTER ST. ANDOVER, MA 01810 SI ST NOTICE ❑MOVED,LEFT NO ADDRESS Q FORWARDING ORDER EXPIRED ATTEMPTED-NOT KNOWN t �er6v ❑UNCLAIMED ❑REFUSED �p0 TO SENDER O NO SUCH STREET . UNITED STdTEt 17 NO SUCH NUMBER aosrdi sEevi�E„ 0 INSUFFICIENT ADDRESS I '� I 4 ET°� The Town of Barnstable 31esa9TeBL i Department of Health, Safety and Environmental Services ""a. 9 k•9 Public Health Division 367 Main Street,Hyannis,MA 02601 Office 508-790-6265 Thomas A.McKean FAX 508-775-3344 Director of Public Health November 27, 1996 Louis Piazza 11 Center Street Andover, MA 01810 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 432 Sknunknet Road, Centerville was inspected on November 15, 1996 by Christina Kuchinski, R.S. Health Inspector for the Town of Barnstable because of a complaint. The following violations of the Town of Barnstable Rental Ordinance Article 51 and the Sanitary Code H were observed: 410.500: The padding beneath the wall to wall carpeting in the house was mildewed. The odor of mildew had permeated throughout the house. Mildew had started to grown on the tenant's sofas. You are directed to correct the above listed violation within seven (7) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, this violation must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject,to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OF TH OARD OF HEALTH Thomas A. McKean Director of Public Health cc: Mary Ferreira F6RM3o HOBBS&WARREN,INC. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , CITY/TOWN b DEPARTM�E��T • - _ �6 � / ��yr .S�- '. c`-f''y�iiL�� ADDRESS 7 TELEPHONE Address y3� /wyf� /�/, (�✓�� Occupant . P Floor— ` Apartment-No.-'- No.of Occupants No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units— -No'Sto ies Name and addr s of owner a2e 02 tf&,V 0./PORemarks Reg. Vlo. 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: 4 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 E 6i . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Su I .Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vents ELECTRICAL Panels, Meters,Cir.: 110 ❑ 220 Fusing,Grnd.: AMP: 'Gen.Cond. Distrib. Box: 'Gen. Basement Wiring: DWELLING UNIT Ventil. Lqtnq.,10utlets ,Walls Ceils. Wind. Doors Floors Locks Kitchen - ,- Bathroom Pantry Den Livina Room Bedroom 1 w - Bedroom 2 Bedroom 3 Bedroom 4 , Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: r- Stacks, Flues,Vents,Safeties: - Kitchen Facilities Sink - Stove - Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: ' Wash Basin,Shower or Tub: Infestation Rats, Mice,Roaches or Other:Egress Dual and Obst'n: General .,. Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED,ABOVE IS•A CONDITION'WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY'AND WELL—BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 `OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over)' ' "THIS INSPECTION REPORT IS SIGNED'AND CERTIFIED,UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR j,�4�y( `� r' TyfL � " D U A'TEx' r/.,/ � a TIME � P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions. Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing. is composed of these 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 410.000 through 410.499 state minimum.requireaents of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so,in every case and therefore cannot be included-in this listing. , Failure to include shall in no way be construed as.a determination that other violations 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 the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it 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 An 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) Shut-off and/or failure to restore electricity or gas. (D). - Failure to supply the electrical facilities iequired.by 105 CMR 410.250(B), 410.251(A), 410.253(A), 410.253(B) and the lighting in- common 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 system-in operable _ _ condition as required by 105 CMR 410.150(A)(1) and.410.300. + '(C) Failure .to provide adequate exits, or the obstruction of•any exit, passageway or common area caused-by, an object,- including garbage or trash, Which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure-to comply with-the security requirements of 105 CMR 41D.480(D). (I) Failure to .comply with any provisions-of 105 CMR 410.600 through 410.6.02 ..`vlfich.results in any accumulation of garbage, rubbish, filth or other causes cif_ 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 i_._spread of disease. • . (J) The presence of lead-based paint on a dwelling or dwelling unit.in violation of the Massachusetts Department of Public, HealthRegualtions for Lesd Poisoning Prevention and Control 105 CMR 460.000. _ (B) Roof,-foundation, or.other structural defects that may expose the occupant or. anyone else to fire, burns,. shock, accident or other dangers or + ' bipafrkent to health -or dafety._ _ (I:) 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 facilities as -Y- 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 of the following conditions which remain uncorrected for a period� of five 'or'moie days following the notice to or knowledge.,of the owner _ of said condition or conditions: (t)— 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 operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410:150(A)(2) and 410.150(A)(3) and any defect which - renders them inoperable. - - __(3.) defect,"in Tthe_electr..ical„_plumbing,- or--heating system-which :makes ._ such system or any part thereof in violation of generally accepted -.plumbing heating,. gas-fitting, 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., (N) Amy other violation of Chapter II not enumerated, in, 105 CMR ,410.750(.A) through .(M) -shall be deemed•• to he's c1 nditlon\wh'i'ch may' eadaeger or materially, fir the health or.safety and well-being of an occupant upon the failuri'of' the owner to remedy said condition within the time so. ordered by the board of health. r , Town of Barnstable �. —Department:of.Health,Safety,and Environmental Services r-'vi Public Health Division ' r) 367 Main Street 3 LI 8 6,59 Hyannis,MA 02601 G NOV � 1 . �27 �V. ,. RETURN RECEIPT R 6138443 LOUIS PIAZZA 11 CENTER ST. ANDOVER, MA 01810 ---- - _1ST_NOTICE r❑MOVED,LEFT NO ADDRESS ❑FORWARDING ORDER EXPIRED ATTEMPTED-NOT KNOWN RfrvR ❑UNCLAIMED ❑REFUSED tiE ❑NO SUCH STREET n To.ENOEF - UNITED STATES _ ❑NO SUCH NUMBER POSTAL SERVICE. -❑INSUFFICIENT ADDRESS - -. SENDER: ■Complete items 1 and/or 2 for additional services. I also wish to receive the I in ■Complete items 3,4a,and 4b. i _ I W ■Print your name and address on the reverse of this form so that we can return this following services(for an I card to you. extra fee): j ■Attach this form to the front of the mailpiece,or the 01i i permit. on back if space does not 1. ❑ Addressee's Address c at ■Write°Retum Receipt Requested'on the mailpiece below the article number. m I r ■The Return Receipt will show to whom the article was delivered and the date 2 El Restricted Delivery delivered. ., o Consult postmaster for fee.13 a ; J.Art A ssed to: 4a Article Num er I la � c 4b.Service Type , 'o A/ ❑ Registered &Certified W i ur f ❑ Express Mail ❑ Insured .y; ❑ Return Receipt for Merchandise ❑ COD i a 7.Date of Delivery Q I ¢ 0 w 5.Received By: (Print Name) &Addressee's Address(Only if requested i Ix and fee is paid) m , / } c 6.Signature: (Addressee or Agent) + IN X PS Form 3811, December1994 _ __ ___ _�_ _ _ Domestic Return Receipt lA toe- �- f l•a TROY WILLIAMS PtCE;✓F, SEPTIC INSPECTIONS 0p ACT 2 8 1997 Certified by MA Department of Environmental Protection r7bEPiae((508)� 5-1300 19 Hununel Drive South Dennis, MA 02660 .9 'b COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �J ONE WINTER STREET. BOSTON, MA 02108 617-292.5500 WILLIAM F.WELD Govcmor TRUDY CORE Sccrctm% ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property^spectto^� a1 d7 Address: Y 3.2 S k u h k t +b I?d. C..,A,,,Address of Owner. Date of 1 /0 / / Lo v Name of Inspector: Troy Williams (If different) /) C`,,", L„. 1 am a DEP approved s tem inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) u. Company Name: Troy .Wirliams Septic Inspections /�irt�lcvt,i Mailing Address: _19 Hummel DriVP , South DPnnis , MA 02660 Telephone Number: T5 0 8T38 5-13 0 0 CERTIFICATION STATEMENT I certify that 1 have personally inspected the si:wage 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: asses Conditionally Passes — Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: /0 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, 8, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: N1/'9 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. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is 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. 1—is.d 04/25/17) P.q• 1 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: '/ 2 3 ,�k - Owner: Date of Inspection: I 0 7 B) SYSTEM CONDITIONALLY PASSES (continued) N �19 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken .or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IT APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1� CERTIFICATION (continued) Property Address: 9 A - Owner: Date of Inspection: a 9 DI SYSTEM FAILS: You must indicate ei;,.er "Yes" or "No" as to each of the following: 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. Yes No Backup of sewage into 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 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 112 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. F) LARGE SYSTEM FAILS: N/17 You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: 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: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of.the Department for further information. (rwia•d 04/25/97) p Page 3 of 10 P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B > CHECKLIST Property Address: 7`�� `l `�` ++ Owner: p c` Z 6- Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes, No Pumping information was provided by the owner, occupant, or Board of Health. 1 C•S L� V��..,�ql L� l _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or / as part of this inspection. SC _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. _ All system components,.excluding the Soil Absorption System, have been located on the site. _ 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. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Y _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)J (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C � pSYSTEM INFORMATION 17 Property Address: S Owner: R Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 2 D .p.d./bedroom for S.A.S. Number of bedrooms: R Number of current residents: D Garbage grinder (yes or no): /t'o Laundry connected to system (yes or no): Nd j3u4 1, s •� l� .JQ Seasonal use (yes or no): IVO Water meter readings, if available (last two (2) year usage (gpd): q 6 = /oZ/,ouJ�, //�,� s �, S = �y qL� , 4/�o H S Sump Pump (yes or no): iVO -i Last date of occupancy: �acc,. c f„� -v r �,vt. 0a t 1, f COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if.available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS andsource of information: l J I NU P a��, S i TL C (G �, �a r n S /✓G fr"c 1 j��t�. �� fiJ �,'K,<r l rrJX �y/ f O !D c r System pumped as part of inspection: (yes or no)L6 If yes, volume pumped: gallons' Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of al components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) No (revimad 04/25/97) r Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / c SYSTEM INFORMATION (continued) �/ Property Address: ,3a Owner: ,Z Z Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: 0 Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age — Is age confirmed by Certificate of Compliance —(Yes/No) Dimensions:_ �� x 5 'X 6 /o�� ,, //u�. Sludge depth: a �' Distance from top of sludge to bottom of outlet tee or baffler r �r Scum thickness: NOil/ Distance from top of scum to top of outlet tee or baffle:X3 JC-IJ Distance from bottom of scum to bottom of outlet tee or baffle: 3 How dimensions were determined: t . Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural in grity, evidence of leakage, etc.) oti s i •. /� ci... vv 7L /c— cl. � GREASE TRAP:�/9 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) (revised 04/25/97) x' Page 6 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM (INFORMATION (continued) Property Address:'/ Owner: Date of Inspection: �v TIGHT OR HOLDING TANK: /'4 (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: 4-- Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) _►� ti c r^c l r .. ✓6 ri �L U r cam( c✓ PUMP CHAMBER: AIA (locate on site plan) Pumps in working order: (Yes or No) Alamo in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Y ' (reviaad 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / /� SYSTEM (INFORMATION (continued) ( Property Address: / '?.2 5 ,j Owner: 1421 c�,_ Z L K Date of Inspection: I o /.-I �' 7 SOIL ABSORPTION SYSTEM (SAS): V/� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: � '�6 ' r leaching pits, number:Jet Lc -C. 4A /'9, 4 y. �•�'(, � S �H c leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) A /- c rt CESSPOOLS: �✓J ' (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: ,e (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.) (revised 04/25/97) P rage ! of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (f c�j SYSTEM INFORMATION (continued) Property Address: / 3a Sk0" 1�—�` /, d - Owner: 0' i tic. L Z 4 Date of Inspection: / C, SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3c,'(- 8� a � , 34 /000 y q I/o n- p- 13dx (revised 04/25/97) '' Page 9 of 10 P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) � Property Address: /3.2 S k Owner: 19,A-..LZ c— Date of Inspection: /O Depth to Groundwater/3.0 Feet d / adjusted high uoundwatct level Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) /4'-r. ofVy c c a� /-A0 !y ro`� ti c� lti/ia-J v ti c� `l.tw�.(t c, cA j -s4 AhLh /yro�J�,�( 13o vti, a S 4- (rwis•d 04/7S/97) Page 10 of 10 i Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 413 S �.� k. { }- /?J . Lot No. Owner: /�; 2 Z w Address: Contractor: Address: Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... 2,0 OB Water-level range zone ..................................................... G STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... �/97 y�.3 month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) v2 determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) .................................................................................... Z 348 659 968 G Receipt for Certified Mail No Insurance Coverage Provided 'ter : o not use for International Mail ee Reverse) O.i Sent o _) t e and � P. late and ZIP otle � ostage CM Certified Fee `o it LL' Special Delivery Fee tir 1 esinc e e iv_ery.a e e urnTRe'_celp�. owing I to Whom&baaie Deliverect Return Receipt Showing to Whom, Date,and Addressee's Address TOTAL Postage &Fees Postmark or Date STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, 'ERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). ( 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address In eaving the receipt attached and present the article at a post office service window or hand it to j your rural carrier(no extra charge). Q) 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return rn address of the article,date,detach and retain the receipt,and mail the article. 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits.Otherwise,affix to back of article.Endorse front of'article RETURN RECEIPT REQUESTED adjacent to the number. O O O } 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, M endorse RESTRICTED DELIVERY on the front of the article. 0 5. Enter fees for the services requested in the appropriate spaces on the frrit of this Iaceipt.If U- return receipt is requested,check the applicable blocks in item 1 of Form 3811. a 6. Save this receipt and present it if you make inquiry. 105603-93-8.0216 yOfTHE TO�♦ The Town of Barnstable DAW,T,M s Department of Health, Safety and Environmental Services mum �, Public Health Division 367 Main Street,Hyannis,MA 02601 Office 508-790-6265 Thomas A.McKean FAX 508-775-3344 Director"of Public Health November 27, 1996 Louis Piazza 11 Center Street Andover, MA 01810 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE II MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 432 Sknunknet Road, Centerville was inspected on November 15, 1996 by Christina Kuchinski, R.S. Health Inspector for the Town of Barnstable because of a complaint. The following violations of the Town of Barnstable Rental Ordinance Article 51 and the Sanitary Code H were observed: 410.500: The padding beneath the wall to wall carpeting in the house was mildewed. The odor of mildew had permeated throughout the house. Mildew had started to grown on the tenant's sofas. You are directed to correct the above listed violation within seven (7) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, this violation must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OF TH OARD OF HEALTH Thomas A. McKean Director of Public Health cc: Mary Ferreira f Ce�1f�uu.tCe.� IM � Mr./Mrs. L ov cr pi, � // C,,4C4,- ��✓ NOTICE TO ABATE VIOLATIONS OF 105 CMR 410,00, STATE SANITARY CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 1/3a SYL�Nkm�- 0j was inspected on I by C�(i� Health Agent for the Town of Barnstable because of a complaint. The following violations of the Town of Barnstable Rental Ordinance Article 51 and the Sanitary Code II were observed: Ifk W,W 7/6 t,�re�GC 'roovu 0 S�a�- 40 o� �( Y are d• ecte to co ct the iolatio w' m 24 ho ,of re of this otic You are also directed to correct the rir above listed violations within seven (7) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Ilealth within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. Enclosed are citation numbers due to violations observed on PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean ' Director of Public Health Town of Barnstable FORM3o HOBBS&WARREN,INC. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN � DEPARTMENT ADDRESS TELEPHONE Address �� vtivicf Ad ��"' "r O111rcc{u-lpant r),Q ,. Floor Apartment No. No.of Occupants f No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units _ No.Sto ies Name and address�of�owner v -C /� 2 (,-0_Yt- ell, 7Lhf'c �`-}�,t,l'�Il/�v �/1•t. 0/iF/QRemarks 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: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: ( Hall Lighting: Of , Ore-44.—_d Hall Windows: HEATING Chimneys: AIM 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.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL—BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." r,/' //� /o / INSPECTOR i(�L�IYU� v�'I i 4lwfl, L U DATE /S TIME- �� / M A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these 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 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations 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 the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it 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, tomeet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 fora 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) Shut-off and/or failure to restore electricity or gas. (D). Failure to supply the electrical facilities required by 105 CMR 410.250(B); 410.251(A), 410.253(A), 410.253(B) and the lighting in common area required by 105 CMR 410.254. (R) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage 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 an object, including garbage or trash, Which prevents egress in case of an emergency 105 CMR 410.450 and .410.451. (11) Failure to comply with the security requirements of 105 CMR 4110.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602 .vhich. results in any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects .nor other pests or otherwise contribute to accidents or to the creation or -:.spread of disease. (J) The presence of lead-based paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. :_(B) 'Roof, foundation, or other structural defects that may expose the Occupant or anyone else to fire, burns, shock, accident or other dangers or Affteat to health -or dafety. (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 facilities 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 'm health or safety. (M) 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: (`t) 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 operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and 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,, gae-fitting, or electrical wiring standards that do not create an immediate hazard. .(r)_ 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. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the o+mer to remedy said condition within the time so ordered by the board of health. "A{FORM30 HOBBS&WARREN,INC. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TON' / W Ak :c DEPARTMENT ADDRESS 7 TELEPHONE t-C- Address y3� "`/rC.<1 �'tC1� /`"�� ' � Occupant Floor-Apartment No. No.of Occupants No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units . No.Sto ies Name and address of owner /V"c t/t%9n f C v kJA J1 U/0(f dRemarks Reg.. Vim YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Draina e 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: r--O d/A f ,mod. 1 L4X Hall Lighting: 0-C U, Hall Windows: �J/�r, fly `f .,uJ �•Y,,. ciyrri�..� HEATING Chimneys: LA_„u. r r' , s r.-r•k.e t , Central ❑Y ❑ N Equip. Repair n h I ,,a,.,r � C'n a r v TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: .0 MS ❑ ST ❑ P Waste Line: ' H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 11220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other:_ Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED'ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." --INS PECTOR C� i(it fY(,�C-Gt cc� �G TI `/'� /`7[ TLES DATE D U / P.M. TIME A.M. THE NEXT SCHEDULED REINSPECTION P.M. i • Y 410.750:: Conditions Deemed io Endanger of 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 these 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 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations 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 the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it 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. .T (B) Failure to provide-heat as required by 105 (MR 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._ _ ' i (C) Shut-off and/or failure to restore electricity or gas. - (D). - Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253(A), 410.253(B)"and the lighting in common area required by 105 CMR 410.254. _ (E) Failure to provide a safe-supply of water. '• .(P) Failure to ,provide a toilet and maintain a sewage 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 an object, including garbage or trash, ` .which prevents egress in case of an emergency 105 CMR 410.450 and .410.451. OW-Failure to comply with the security requirements of 105 CMR 41.0.480(D). (I) ...Failure to comply.with any provisions of 105 CMR 410.600 through 410.602 =.:nbich.results in any accumulation of garbage, 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 lead-based paint on a dwelling or dwelling unit in .violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. _=(K) 'Roof, foundation; or.other.structural defects that may expose the occupant or anyone else to fire burns,burns, shock, accident or other dangers or iiN tt nt to health -or dafety. (�) Failure`to- install electrical, plumbing, heating and gas-burning F - .facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilities as - are`required+by 105` CMR 4i0.351 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-of the following conditions which remain uncorrected for a period r_ of five or more days following the notice to or knowledge of the owner_ of said condition or conditions: 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 operable. - (2)-- failure to provide a washbasin and a shower or bathtub as- required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and 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,, gas-fitting,, or electrical wiring_standards that do not create an immediate hazard. O failure toymaintain 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. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition 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. 3............. .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �..®w ..---.-"......OF.......... ......................... Applirntiou for Ut4pnsal Workii Towitrurtinn runfit Application is hereby made for a Permit to Construct (L-f or Repair ( ) an Individual Sewage Disposal System at: .............. S K V :.?�d ...... -��.................... ......----...._�-:5��........��...................................................... Location-Address or Lot No. .................. ........... ------. ............ ._......--...... R•(J ST ._ �... ............-•--------............... Owner Address a -v-EzK`N 3-s _d ....... .N.. . .c Q�t- Installer Address dType of Building Size Lot.-\i�-: -- .......Sq. feet Dwelling—No. of Bedrooms............3.............................Expansion Attic ( ) Garbage Grinder (tea) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .................................. W Design Flow.................. a................gallons per person per day. Total daily flow............. 330_._.._.__......gallons. WSeptic Tank—Liquid'capacitylV?.(?. .gallons Length................ Width-______..__-_--- Diameter---------------- Depth................ x Disposal Trench—No..................... Width........:........... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( . ) Dosing tank ( ) '�' Percolation Test Results Performed by------------ aJ�_g_G .....�._.� £........... 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........................ ----------------------------------•----•--•-------•---.....-•-•--••------------..... ...... •---------------------------------------- ----------- •--------- 0 Description of Soil......... .............. ............'c..---•............ so ......--•--•--•--•-•-•-•--------••---•---••--------------•- cx> .......................................a" -•-------------• �. .......... s ----------------------------•--•-------------------------------------------------•-----•---- W --------------------------------------- -a"------------..... .a 5 N-R........................................................................................ 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 TAIT1, 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------ N.\k .----N�' --------------•--------- ..........................— Date Application Approved By.............. .� i... ..... J.'„ - 1, Date Application Disapproved for the following reasons---------------••---------------•------------------------------•----------------•----------------------•-•----•-- -•-•--------------------------------------------------------- ------------------------------------------------ ---------•---------------------------------------------------------------------------- Date PermitNo......................................................... Issued-...................................................... Date No..S t .. "7...... ....... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH Applirution for Elhipos al Wnrko Towitrurtion Prrutit Application is hereby made for a Permit to Construct (L-1 or Repair ( ) an Individual Sewage Disposal System at: .......... - v i -u ... �� - - L:.��. ........................... - ---------- _ Location-Address or Lot No. `�ft rn-�s \` s.m �:�. ....-•....... ...........•---I�A-.........................�Z---V= .................................... _ po Owner Address Installer Address Type of Building Size Lot.Si - 0.r_\A...._..Sq. feet N.•1 Dwelling—No. of Bedrooms..................._........................Expansion Attic ( ) Garbage Grinder NO) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) G 1 Other fixtures ...---•-•--••-- •-•------•--•--•----•-----•-•---- W Design Flow....................�::�....._._.....__..gallons per person per day. Total daily flow................-�_-3-`?-.•------------gallons. � Septic Tank—Liquid capacityk9g -,..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.......... �L. .."C. -: ..... ..._Qyc............ Date..... a_::�.5_=_`� �...•.._.. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ;X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___-_--------------_--. 04 ..........--•...............................•-......•-•••-•--------.......-•----•--•-------.............--•-•-..............._.........----•-----•---•-.•---- D Description of Soil......... a ......... L t7_C��n...........c.....---•--... <— U --•----------•-•••••---••--•--••----•--•�'--�...........-•-•- -- -- ----------`' ----------------•-•---------•--•---------------•-•------•---........---...._..._..... . -----------------------•-------•-------...----...-•------------.......--•-----•---- U Nature 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 AITTIE 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. : t : Y. ---•----• ----- .Dac .� �a Application Approved By..... " .. - ' � '-•..... ------...... 13- Date Application Disapproved for the following reasons:................................................................................................................ Date PermitNo......................................................... 1 Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............\. `>>..n..........OF........l� .l.�.n. ................................... ...... %rrtifiratr of Tuutpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (t.I or Repaired ( ) by............... U` Cti Installer .at ------ ................................. has been installed in accordance with the provisions of TIT IE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... 5 .. ........... dated_................................................ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..........................................5:-` •-.6 ................... Inspector......... ;,Z.t.d�t.--•-•--•••---•--•-----------•----------•--------•--.------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r, OF...................i o r f r t=`' ...................... No .......................................... �L j FEE...................... urk� C�uat�trurtiuu rrutit Permission is hereby granted.........v 1 nu to Construct ( vj or Repair ( ) an Individual Sewage Disposal System, atNo. ............... v - -_ C .............. -••--•---..._. n �'P........... ....-.........-• Street as shown on the application for Disposal Works Construction Permit No--------------------- Dated.......................................... ® `l-�L s DATE .................................................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS Stt,.I�Gt_� FAilntt��! - 3 ��>::•.ver�oM � � _ � �.,., .:. . 1 ?aat LK Flows 1t0 � 3 s '3�0'�:�•tv 49`?6-p-0. i USA- 1000 6A L.. �t�PosAL Prr ��,F l000 ��,_ •� 25� . : � '� -. . � � ` IUEWAL.L AZEA L 150 S F. Fit rO�c� A2�A+ sr-. CEO frF'. -- ToTAL UE.SIGtJ a ZSS GRD. i i rWK ;41�3 0 ��i _. .TOTAL �att_�f FLOWS 33D6s�•_ � : ' : �'� ��:�'�'` .� i � t"ItJ Sm1►J� D2 Lr:Ss.� KOfAt'�,e'�,; RICHARD - - : - t n BAx-mi ' ,l.. 5 { i Tor F".!o 41•'5 4. e� . .. . . . . d,ppe loon IMl �;, luv T"AkW. I , - GAL,. : �!S•'Z- `"( _ - - . ' . . � ' :• .. .. 5Aa� FlT yj . , cceTlFlEn n�o-r- Pt-. >J 1roCATIo" WAIIU.:ITP 1'L' u o resc 4L�.= i C f� ..... l��•4�� Y3 a"T� �../�.t/��L.. CGtZTtF%4 TNA't- Tj*4G6 D.ATioN su�'� WE-2 m ow Go4APL V 5 w ITN Tta;=: -$I Ur.LI►-tE= AutD 5C'C1'.AGIG lVGQUlrlGAAE:uTS of Tz- Olr 1Z. L l�s�bN ITO I S �Cr LOGATEb PLAI W. U4T Z : eA.XTaV, 4.IYE t�G. t2cGt51ztZED Ut.Wo StJeVE-Yotz. "('1-115 C7�A t•.1 1 S Lt OT t�AS G� U t.� A�•l - osTE�v�L.t..G o MASSY ;1.1C,wLp ANPL-tC.-A•ti-1_T l t -r ram !lr C [-1 .'T. . l�[�'TGCMI►Jl LOT - �-1