HomeMy WebLinkAbout0034 STRAWBERRY HILL ROAD - Health pp
34 STRAWBERRY HILL RD. , -CENTERVILLE
A=246-070
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UPC 1253.4
No.2_ 1�53LOR °
HA8TIN08,UN
Health Complaints
18-Jul-05
Time: 7:45:00 AM Date: 7/14/2005 Complaint Number: 18270
Referred To: DAVID STANTON Taken By: DAVID STANTON
Complaint Type: GENERAL
Article X Detail:
Business Name:
Number: 34 Street: Strawberry Hill Road
Village: CENTERVILLE Assessors Map_Parcel: 246-070
Complaint Description: ANOTHER COMPLAINT COMING INTO OUR
PERSONAL PHONE LINES, CHICKENS
MAKING TOO MUCH NOISE.
Actions Taken/Results: DS WENT TO SAID LOCATION. NO
CHICKENS OBSERVED. DS KNOCKED ON
DOOR, A GUY ANSWERED THE DOOR
THAT SPOKE BROKEN ENGLISH, AND
LAUGHED AND SAID NO WHEN I ASKED IF
HE HAD CHICKENS. DS TOLD
COMPLAINANT THAT CHICKENS ARE
TYPICALLY NOT A NOISE VIOLATION, AS IT
IS NOT CONTINUOUS. NO VIOLATIONS
OBSERVED, NO FURTHER ACTION
REQUIRED.
Investigation Date: 7/14/2005 Investigation Time: 3:10:00 PM
1
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No. � Fee$5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Z(pplication for Migonl *p5tem Conztrurtion Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. aj
Owner's Name,Address and Tel.No.
Assesso 's e0rawberry Hill Rd. Ivan Belaeff
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Ser.
P O box 1089,
Type of Building:
Dwelling No.of Bedrooms h Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Tit 1 e-`>—septic s y s t eat
consisting of a 2,000 gal, tank, pump station/pump/ alarm
and 4 concrete leach chambers with stone all around
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by tl opd of Health.
Signed Date 0=6
Application Approved by i Date
Application Disapproved for the following reasons
Permit No. �s `�"Y?2 Date Issued Z 9 ` _c�Z
� 6 Fee$50
No.-
' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
'4' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
1 L_. 7C
'application for Miopo6aY 6pMem Construction ermtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
&4Y
Assess o 's Strawberry Hill Rd.Centerville Ivan Belaef f
_�-
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 4
Wm. E. Robinson Septic Ser.
P 0 box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms,, 6 Lot Size sq.ft. Garbage Grinder( )
Other i Type of Buildings No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic sygtom
consisting of a 2,000 gal. tank, pump station/pump/ alarm k '
" V --and 4 concrete leach chambers with stone all around
Date last inspected:
Agreement: Z
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal sy"stem
° in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bood of Health.
Signed Datet `..
y-.. Application Approved by Date .—/z_
E Application Disapproved for the following reasons �— A
Permit No. or_ '� Date Issued Z I 2
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
i BARNSTABLE, MASSACHUSETTS
Belaeff (Certificate of Compliance
THIS IS,TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( )
Abandoned( )by Wmj_ E. Robinson Septic SArvi cg
at 34 Strawberry Hill Rdl , Centerville has been constructed in accordance
t._ with the provisions of Title 5 and the for Disposal System Construction Permi !G «.' �J dated
Installer Wm. E. Robinson Sr, Designer
The issuance of this permits 11 of be construed as a guarantee that the sy ill fu designed�f
Date 2 Inspector / `
---------------------------------------
No. ^1`lf-i' Fe4 5 0
�✓ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC H �ALTHµDIVISION - BARNSTABLES MASSACHUSE�TTS"
Belaeff =1i6pool *p! tem Con5truction Permit
Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( )
System located at 34' Strawberry Hill Rd- ,, CPntcarvi 1 1 e
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this it.
Date: ��ii '.� /,� Approved b -
116M
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTMCATION OF SKETCH AND APPLICATION FOR A DLSPOSAL
WORKS CONSTRUCTION PERMff(WTrHOUT DESIGNED PLANS)
I. W i 11 iain E. Robins on,sllereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at 34 Strawberry Hill Rd. , Cer tervillepneen all of the
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling-
The soi I is classified as CLASS 1 and the percolation rate is less than or equal to S nunums per inch.
There me no wetlands within 100 feet of the proposed septic kystem —
There Lrc no private wells within 150 feet of the proposed septic systeni
There is no increase in flow and/or change in use proposed
• There no variances requested or needed.
• The m of the proposed leaching facility will nQt be located less than five feet above the
=,a uro adjusted groundwater table elevation:[Adjust the groundwater table using the Frimptor
meth when applicable)
• if S.A-S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
1 g facility will m be located less than fourteen 114)feet above the ma.+cimum adjusted
water table elevation,
Please complete the foAawimg: cs
M Top of Ground surface Elevation(using GIS infomation) i
B) G.W.Elevation _ +the MAX. High G.W. Adiustmmi
DIFFERENCE BETWEEN A and S ` t
SIGNED. . v ✓�' DATE:
{Sketch proposed plan of system on back).
y:heaM foWa oat
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I
Health Complaints
10-Apr-03
Time: 10:20:00 AM Date: 3/27/2003 Complaint Number: 3969
Referred To: DONNA MIORANDI Taken By: DENISE PERRY
Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH
Article X Detail: ILLEGAL OPERATIONS
Business Name:
Number: 34 Street: STRAWBERRY HILL RD
Village: W HYANNISPORT Assessors Map_Parcel:
Complaint Description: COMPLAINANT STATES DUMPSTER HAS
BEEN MOVED TO PROPERTY LINE...LAST
YEAR YOU HAD HIM MOVE IT 10 FEET IN
FROM PROPERTY LINE.
Actions Taken/Results: SW spoke with complainant about problem with
dumpster. Will be stopping at said address on
Monday, 3/31/03 to observe where dumpster is
being kept. SW and DD observed wooden
trash container within ten (10)feet of front and
side property lines. SW issued a written
warning to the owner of the property(Mauro
Rivera) giving seven (7) days to move the
container, using the correct setbacks. SW re-
investigated site on 4/7/03. Container had been
moved more than 10'from the street and
adjacent property line.
Investigation Date: 3/31/2003 Investigation Time: 2:30:00 PM
1
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TOWN OFBARNSTABLE BAR-Wme 3827
` Ordinance or Regulation
,WARNING NOTICE
Name of Offender/Manager ,.
Address of Offender /. � '%' �'1 V�, k-1f)_MV/MB, Reg.#
Village/State/Zipv' ,/ C' Iid�t.- % , P1 r-�� ,;�
Business -Name k�_/pm; on 1 7 20
Business Address
Signature bf En°forcing Officer ,
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Village/State/Zip � +'�. '�
Location of Offense. a' I / U/ ,',% / /fr
Enforcing De t/Div'is°ion��t
Offense1
Facts / fw f 1 tJ tV r1
V/- -,,A() M 0j"r" Z0 LJP' A V 9 h'5110/ 0/? f
This/ will serve only. as 'a warning."At this time/no legal `action 'has `b"een° taken.
It is the goal of Town agencies to .achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
' TOWN�OF BARNSTABLES µ BAR—W 27
r Ordinance or Regulation ,.
-WARNING NOTICE
1
Name of Offender/Manager 7 .
I Address of Offender r � / ,_' ', MV/MB Reg.#
V l e/State/Zi I3 r` r �»-
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3 *. $usiness Name /P on ?1W20
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Business Address
Signature of Enforcing Officer
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Village/State/Zip
Location of Offense % a r r r"� j/ �V � �'� at t� f �
' f Enforcing Dept/Div,-ision
Offense .✓fit {.i I � 4 � ,
Facts ,, , . 'ii,"' ' r � .1 � �, f - � fs }
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This! will serve only as a warning."At this time/nof1egilYaction` has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
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Health Complaints
26-Sep-01
Time: 11:00:00 AM Date: 9/14/01 Complaint Number: 3076
Referred To: DONNA MIORANDI Taken By: FLORENCE SMITH
Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH
Article X Detail: UNSANITARY CONDITIONS
Business Name:
Number: 34 Street: Strawberry Hill Rd.
Village: HYANNIS Assessors Map-Parcel:
Complaint Description: Trash is blowing everywhere from the wind.
Actions Taken/Results: DZM investigated and issued a warning notice.
New owner of property is Mauro Rivera, 83 Old
Craigville Road, Hyannis-phone#771-3435.
Property was cleaned up next day.
Investigation Date: 9/14/01 Investigation Time: 4:30:00 PM
TOWN OF.BARNSTABLE
LOCATION SEWAGE
VII.LAGE ASSESSOR'S MAP & LOT Z96-070
i INSTALLER'S NAME&PHONE NO: W Le &6 ,),mo -7 —9,77 4
SEPTIC TANK CAPACITY_;ppo
LEACHING FACILITY: (type) 2h Am d.-5 (size)
NO. OF BEDROOM_ S S 6
nuLLLJt&UK OWNER <.JU919
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and.Leaching Facility (If any wells exist' .
on site or within 200 feet of leaching facility) Feet
Edge-of Wetland and Leaching Facility(If any wetlands exist
Within,300 feet of leaching faciLty) ".;.. Feet
Furnished by
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Z 273 502 635 ,
US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not u for International Mail See r,verse
Sent to
St Num e
Po Ic , IP Cod
Postage $
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
u�
rn Return Receipt Showing to
Whom&Date Delivered
Q Return Receipt Showing to Whom,
Q Date,&Addressee's Address
0 TOTAL Postage&Fees is
er
M Postmark or Date ) �y
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01
a.
Stick postage stamps to article to cover First-Class postage,certified 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 leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge). ti
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m
return address of the article,date,detach,and retain the receipt,and mail the article.
LO
3. If you want a return receipt,write the certified mail number and your name and address rn
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 a
RETURN RECEIPT REQUESTED adjacent to the number. Q
4. If you want delivery restricted to the addressee, or to an authorized agent of the O
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addressee,endorse RESTRICTED DELIVERY on the front of the article. M
5. Enter fees for the services requested in the appropriate spaces on the front of this E
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. to
6. Save this receipt and present it if you make an inquiry. 102595-99-M-0079 a
FORM30 CAW HOBBS&WARREN rn THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY/TOW N
W 1-ka V
o DEPARTMENT
' l ADDRESS
�A � ,-TTELEPHONE
Address S'(rpw��r�Y �' f j `L Occupant U��
YA
=—
Floor Apartment No._ No. of Occupants
No.of Habitable Rooms/ No.Sleeping Rooms -__
No. dwelling or rooming units_ No.Stories_-
Name and address of owner SC.w�
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other: �o
STRUCTURE EXT. Steps,Stairs, Porches: Ili® C--c4 j
_Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows: ( ( L )
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen. Sanitation:
Dampness: _-Cl-v
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Li htin : <—O 1-
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N E ui . Repair Z 'Lve..o) j v
TYPE: Stacks, Flues,Vents: L,,W 6' atM 4- p p,,rl d
PLUMBING: Su I Line: L �
ElMS ❑ ST ElP Waste Line: -S,e &-jile av
H.W.Tanks Safety and Vent(s)
ELECTR,hCA�_ Panels, Meters,Cir.: L. 64
❑ 110 �220 Fusing,Grnd.:
AMP: G00 Gen. Cond. Distrib. Box:
Gen. Basement Wiring: Vk:
DWELLING UNIT Sr^�ol
Ventil. L tri . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen N ova e /o y�L
Bathroom tower
Pantry6rv�-
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,CA Oil, Elect.: 0
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink `Z (lct-4,cd(4,v-r ( yin dAAl (�l
Stove 64--S
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Buildin Posted �-v�-
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) , �J
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJU Y." -7�-h C v
INSPECTOR �- "r TITLE Cb""� J -eve- J
izO
DATE (,j TIME `��� P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
r 'e7 ."�e F' i Tr"r1,�:t by .+`r.fr:y:tiy f:r. T �i.!Id ^V''v,,,..yy � •:h n xS,Jc. rS ri,r ,t �`Sil 1 ...e;:.rtr'...�:v:.a
• 7' x,_5 .•.1,'�N. �.1't�, .i ti p• :J'T' r'.^ZG �'D .t. i'!1 W'�}i t���� ry 6hf4�
. 1 ��[•i,>-1'G. .IKrP. fi'rIF•� ''.� �.tJ
R. 1
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 heaith, or safety and'well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is-not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom.the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
t
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock;accident'or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P)' Any other violation of 105'CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board�of Health.
A r • '
i U
.FORM 30 C&W HOBBSBWARRENTM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
5 kti (e
CITY/TOWN
a DEPARTMENT
ADDRESS 76 2 416
"
Sye�
TELEPHONE /!
Address? .S� � *4r
N 'GW ,-+ ` (A �����Occupant— lie 14-e 7"'7111 -
Floor--Apartment No.— ___ No. of Occupants
No. of Habitable Rooms No.Sleeping Rooms___?4j�yr f ? alowv�
No.dwelling or rooming units_______ No.Stories_ Z-
Name and address of
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other: 4-0
STRUCTURE EXT. Steps,Stairs, Porches: C&
,�,• Rual''E `r6 s:,and Obst'n.: `
' ❑ B ❑ F ❑ M Doors,Windows: 1 I V C( ) S tv tt(- )
Roof
Gutt Xs, Drains:
z, Walls:`
Foundation:
Chimney:
. BASEMENT Gen.Sanitation:
Dampness: tiv
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting: 0 h
Hall Windows:
HEATING Chimneys: 6 t<
Central ❑ Y ❑ N E ui . Repair Z, "Lwi-0) j v f dnv
TYPE: Stacks, Flues,Vents: v 4 14'- i r c v,- rc,•, + o,_ Gx.r.,
PLUMBING: Supply Line: Tva.h 1.4
❑ MS ❑ ST ❑ P Waste Line: -Si*_ (pJS ov /
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.: fv1c A4.4,l <tAa1111 /a
❑ 110 �0 Fusing,Grnd.:
AMP: /00 Gen.Cond. Distrib. Box:
Gen. Basement Wiring: V(<
DWELLING UNIT S 0k4
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks dots
Kitchen M 41rz-
Bathroom a.. trwj__
PantryF�rvr-
Den
Living Room
Bedroom(1)
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten., a Oil, Elect.: 0()
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink o /3 2 ('���Fc(�r,H r 1 vn 4-
Stove CC-
Bathing,Toilet'Facil. Vent.,•Plumb.,Sanit`n.:
Wash Basin, Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Buildin Posted 06N i L, I I W i
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 ( /el
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND U
PENALTIES OF PERJU Y." -7 7 7 O
INSPECTOR C l`-"r TITLE ��-
DATE (y f,44)
TIME ��=C/Z) 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 heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and t4mperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by,105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410,250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254. !
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) .Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0) shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
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Business/Occupant Name � � IVAN BELAEFF
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SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) I 13 Date of Delivery
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse C. Signature
so that we can return the card to you.
■ Attach this card to the back of the mailpiece, X gent
or on the front if space permits. dressee
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to If YES,enter delivery address below: ❑ No
I
3. Service Type
✓(� Certified Mail ❑ Express Mail
Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
t((/J 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number(Copy from service label)
PS Form 3811,`July,1999 ;; I jQomestic Return Receipt 102595-99-M- 7789
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UNITED STATES POSTAL SIRS �dIGE First-Class Mail
c�• Postage&Fees Paid
'' ' _. LISPS
Permit No.G-10
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• Sender: Please print.y_our name, address, and ZIP+4 in this box •
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(Public Nalkiq,Division
TOM of Bamstable
F.0�Box04
E Musetts O28�t
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
V
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS,
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 34 Strawberry Hill Rd. RECEIVED
Centerville, MA
Owner's Name: Ivan Belaef f CYP/�k o 7 ���1
Owner's Address: Game
Date of Inspection• TOWN OF EgRNgTABLE
'f 8 HEALTH DE PT.
Name of Inspector: (please print) Wi 1 1 i am E_ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 7 5-8 7 7 6
CERTIFICATION STATEMENT
I 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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to S ion 15.340 of Title 5(310 CMR 15.000). The system:
to
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: � �t� r _ Date: �L-?-D
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanh,)or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of l 1 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 24 Strawberry Hill Rd.
Centerville
Owner: Belaef f
Date of Inspection: �L —1—
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys m Passes:
1 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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repair d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answ r yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
expla" .
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
ex' ing tank is replaced with a complying septic tank as approved by the Board of Health.
*A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indi ting that the tank is less than 20 years old is available.
ND ex lain:
bservation of sewage backup or break out or high static water level in the distribution box due to broken or
obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND ex ain:
e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass ins ection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
t
Page 3 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 34 Strawberry Hill Rd.
Centerville
Owner: Be aeff
Date of Inspection: 2 -7--6 7
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 failin to protect public health,safety or the environment.
1. rstem will pass unless Board of Health determines in accordance with 310 CNIR 15.303(1)(b)that the
s stem is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
sy tem 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 front a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 34 Strawberry Hill Rd.
Centerville
Owner: Be aef f
Date of Inspection: 7--17-0
D. System Failure Criteria applicable to all systems:.
Y6A must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than''/s day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
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 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. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
T e considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You ust indicate either"yes"or"no"to each of the following:
(The flowing criteria apply to large systems in addition to the criteria above)
yes n
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
he system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped ..
one II of a public water supply well . 4
If you ha a answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in ection D above the large system has famed.The owner or operator of any large system considered a
sigm iic qt threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. he system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 34 Strawberry .Hill Rd.
Centerville
Owner: Be aef f
Date of Inspection: 2-— '7— 0 �
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes o
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?
_Y 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)
1/ 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:
Yes no
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(3)(b)]
5
Page 6 of I 1
r
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 34 Strawberry Hill Rd.
Centervi e
Owner: Be 1 ae f f
Date of Inspection: a_6�2 y G l
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):f b
Number of current residents: l—,
Does residence have a garbage grinder(yes or no): D
Is laundry on a separate sewage system(yes or no) [if yes separate inspection required]
Laundry system inspected(yes or no):AL-®
Seasonal use: (yes or no):Ai�
Water meter readings, if available(last 2 years usage(gpd)): 2000 52,000 gal.
Sump pump(yes or no): 17- 0 1999 47,000 gal.
Last date of occupancy: L--7—6 7
C MERCIAL/INDUSTRIAL
Typ of establishment:
Desi n flow(based on 310 CMR 15.203): gnd
Basis of design flow(seats/persons/sqft,etc.):
Gre a trap present(yes or no):
Indu ial waste holding tank present(yes or no):
Non sanitary waste discharged to the Title 5 system(yes or no):_
W r meter readings,if available:
Last date of occupancy/use:
OT ER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: / 17 O a
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP F SYSTEM
eptic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date in called(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): D
6
Page 7 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 34 Strawberry Hill Rd.
Centerville
Owner: Bela ef f
Date of Inspection: ,
B ILDING SEWER(locate on site�plan)
Dep below grade:
Mat rials of construction:_cast iron _40 PVC_other(explain):
Dis nce from private water supply well or suction line:
C ents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade: _
Material of construction: oncrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) I V Ty
Dimensions: G �-
Sludge depth: t y
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 4�
How were dimensions determined: �cJ
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.):
7 3 �-
GR ASE TRAP:_(locate on site plan)
Dep below grade:_
Mater al of construction:_concrete_metal_fiberglass polyethylene_other
(expla ):
Dimei sions:
Scum hickness:
Dista ce from top of scum to top of outlet tee or baffle:
Dista ce from bottom of scum to bottom of outlet tee or baffle:
Date Pf last pumping:
Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as rel ted to outlet invert,evidence of leakage,etc.):
7
Page 8 of H
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
a
SYSTEM INFORMATION(continued)
Property Address: 34 Strawberry Hill Rd.
Centervillp
Owner: Belaef f
Date of Inspection: 0 --/
TI T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materi 1 of construction: concrete metal fiberglass_polyethylene other(explain):
Dimen ions:
Capaci gallons
Design Flow: gallons/day
Alarm resent(yes or no):
Al level: Alarm in working order(yes or no):
Date f last pumping:
Co ents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: z(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:-
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP HAMBER: (locate on site plan)
Pumps n working order(yes or no):
Alarm in working order(yes or no):
Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 34. Strawberry Hill Rd.
Centerville
Owner: Bel off
Date of Inspection: 0
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
eaching pits,number:_
leaching chambers,number
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
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: ,i
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PR (locate on site plan)
Matter als of construction:
Dime sions:
Dept of solids:
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 34 Strawberry Hill Rd.
Centerville
Owner: Belaef f
Date of Inspection: 3.-,B 2—U J
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
A eta
j
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 34 Strawberry Hill Rd.
Centerville
Owner: Belaef f
Date of Inspection: 9
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
=Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you esta lis d the high ground water elevation:
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Name of Offender/Manager U y-d (164tQ
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Address of Offender 7 ,�` - .ttl, ,-�� l, ,1�! ,fi'd'• MV/MB Reg.#
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Village/State/Zip • 60_A#1ja9).,f
MA- 62& 3 2.
Business Name "`" """"" 6y am/m;. on { 20A3
Business Address �. �
Signatdre. of Enforcing Officer
Village/State/Zip
Locat on,,of Offense " [uf r �,• ,/ r f'l,cf A e'AI' ..G•)1
f ,� f Enforcing Dept/Division
Offense. Y//S -f�' fy'1IS' e e--t �!
Facts toe '74'4S/j ►
f s ru X, 3,ll`e'� / ) 4&/X YD T s
This will serve only as a warning. At this time no legal action has been to"ken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town. ~~
WHITE-OFFENDER CANARY-ORD./REG.-PROD. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
" ; �:'F "TJ 'T�....-r9- eA�•-rA:c.-^�e T";s 1. :.r'r"'t x_T'; "?-.s{""'tF".^"'" T F'<"-,.. 9'a�".'k f ,.h y �.,.,�� y.�-.. ...H.
TOWN OF BARNSTABLE BAR-W
Ordinance or Regulation
WARNING NOTICE
Name of Of fender/Manager / j f 6 101 ve,41,4
Address of Offender ? i MV/MB Reg.#
Village/State/Zipa //t�/ �+'/S.l e (-)2(1 3 .
Y Y
Business Name am/gyp or
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Business Address
Signature of Enforcing Officer
Village/State/Zip
Locatioh,, of Offense ,le - Ile'a4/-4 k"
Enforcing Dept/Division
�
Offense.
Facts tr'f � <n7 'r
This will serve only as a warning. At this time no legal actionfhas been ta`keri.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
Health Complaints
03-Apr-03
Time: 10:20:00 AM Date: 3/27/2003 Complaint Number: 3969
Referred To: DONNA MIORANDI Taken By: DENISE PERRY
Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH
Article X Detail: ILLEGAL OPERATIONS
Business Name:
Number: 34 Street: STRAWBERRY HILL RD
Village: W HYANNISPORT Assessors Map_Parcel:
Complaint Description: COMPLAINANT STATES DUMPSTER HAS
BEEN MOVED TO PROPERTY LINE...LAST
YEAR YOU HAD HIM MOVE IT 10 FEET IN
FROM PROPERTY LINE.
Actions Taken/Results: SW spoke with complainant about problem with
dumpster. Will be stopping at said address on
Monday, 3/31/03 to observe where dumpster is
being kept. SW and DD observed wooden
trash container within ten (10)feet of front and
side property lines. SW issued a written
warning to the owner of the property(Mauro
Rivera) giving seven (7) days to move the
container, using the correct setbacks.
Investigation Date: 3/31/2003 Investigation Time: 2:30:00 PM
1
TOWN OF BARNSTABLE �✓
LOCATION S4rA be-rrV rf I SEWAGE # a0cn----?3'a
VILLAGE ✓ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO �/✓e E ,Ro6t-7s�� �J�S�;R�7
SEPTIC TANK CAPACITY 2,060 a A I
LEACHING FACILITY: (type) _-it- e-hAML S (size)
NO.OF BEDROOMS •-6
BUILDER OR OWNER �3efg��F
PERMIT DATE: ScQ0 COMPLIANCE DATE: OZ O�-
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair anAndividual Sewage Disposal
System at:
2 r _�d4d,
Septic Tank—Liquid capacity_/6i�
,j W- n Le th ----------- Width�............... Diameter------_-------- Depth----------------
--`--`````---`----`-`-----``----'----------`—'-----'-------'----------'---The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has_An i d bby thhe board�off healtl,..
�
Date
Application Disapproved for lie-following reasons:..........................................:.....................................................................
�
Issued........................................................ �
Date
No.--------- Fas...... %.......�'/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........----OF............................................................................I.......
.....
Alip irtttion -for Uiopoiitt1 Works Tatuilrurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System t: r
-•. _
------....� - - --------------- �-�, r
Locationffjj ddress__ `� / or Lot
............••......... i^��Y �_.... `/1./ — J' / <_ G—. ...
"................ ....... .... , ---•----------------
W � .. Ad.....
Installer Address
Q Type of Building Size Lot... jZ....Sq. feet
U Dwelling—No. of Bedrooms----- ............................. -Expansion Attic ( ) Garbage Grinder _V
per, Type g p Showers ( ) — Cafeteria ( )Other—T e of Building ____________________________ No. of ersolt�.______.__..___...._._.__._.
a' Other fixtures ------------------------------- --
W Design Flow............`?._U........................gallons per person per day. Total daily flow------ '��' ........................gallons.
WSeptic Tank—Liquid capacity/0-plions � L e Z h�-_____-_____ Widtl----------------- Diameter---------------- Depth----------------
x Disposal Trench—No. __.�._ ...?__.W dth....f ....... 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 ( )
aPercolation Test Results Performed by....... .................................................................. Date--_------------------------------------
,� Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..------.------.--.--. -
f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--..-.---_---_----------
- -------------------- ---------------------------------------------------------•-•----------•-----.......................................--................
ODescription of Soil---------- --•-----•.......................•----•---------------•--"----------""•-"-..._...-----------.--.---._-.---"---------------------------------------------------
U --------------------------------------- --------------------------------------•--•------••••-----------------•--•---•--•••-•-----••----..............._...-•--------------...._._...._------------.
W
---------------------- ----------------•---------------.------•-.--•--•------------------------------------------------------------------•---------------------------------------.------•-------------
V 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has Sanitary,
issTed by the boar of health. f
Signed /`f w ........................................j? --- ---c-- b
' Date
ApplicationApproved BY -----------------------------•----------------------------------------------------
Date
Application Disapproved for,�he following reasons:................................................................................................................
--------------------------------------------------------------------------------------------------------•-----------------------------------------------------------------------------------------------
Date
PermitNo.-- --•f_3....................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS 6'
BOARD OF HEALTH
l/'�cL T/
Trrtifiratr of 0-omphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by .._.... `7f< C= J/LG/a«
Installer
at..------GUI"...--�-----------: �'�`` / Installer
/U//Lc
- ---------------------------------------------------------------------
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.--. 3----------------------- dated------- ..............
11
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
/ � �-
DATI _ ---------------------------•--------•---- Inspector ---------------•-------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF..............................................................•----................. /
No.--- -------- F E E. 12..`''/ .
�i��o�ttl ork,� (non�trnrtio�t �rrmit
Permission is hereby granted.--"----- J h..y. r ( G !`L�
to Construct (✓ ) or Repair ( ) an Individual Sewage Disposal System_
at No......../e r ............ r,! d'(v.........12=/G G.-•---""-'-------C `- ,T��2 //C C
Street
as shown on the application for Disposal Works Construction Permit No._,..,?�/_j,_.... Dated_...=....�e�. .!_l_....
------------------•-----•------------------- = /';-f�=j�..
Board of Health /
DATE " S- - - L.- -- 76= �a
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i�
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g�-�w � �a,U ►�bA"�e.�1� trr>��''u�.t�
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LOCATION SEWaGE PERMIT Uo. . :
VILLAGE
1I�ISTpLLERS IJ�ME ADDRESS
BUILDERS Q &ME ADDRESS
. � .1T - - - - -=- - - - -
Dts,TE PER"I-T ISSUED
DATE CONIPLI &KIC'E ISSUED ;
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