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HomeMy WebLinkAbout0016 SYLVIA LANE - Health _ 16 Sylvia Lane, Centerville _ A- 189-079 i I No. 42101/3 ORA ❑ a ESSELTE 10% © O O I . f I ' n1 . COMPLETE SECTION COMPLETE ■,Complete items 1,`2,and 3.Also complete A. Signatu :.3`'"':_. item 4 if Restricted Delivery Is desired. X NEEI gent ■ Print your name and address on the reverse ddressee so that we can return the card to you. B. Received 'rated Na. C� Da f Delivery ■ Attach this card to the back of the mailpiece, ; K � — O N ' or on the front if space permits. D. Is delivery address�!'. rat from fte t�a es 1.Article Addressed to: If YES,enter delivery s. �`1 ❑No I ® �� 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑rYes � 2. Article Number _ T" t e 7 -r7 _ ! 1 V (Transfer from servlcelabel) ' �1 7.0061 21-501100021)1042 i0743�1 1� f PS Form 3811,February 2004 Domestic Return Receipt 10259e-02-M-1540 ,e��g g 9. COO: $ ,( { p MiNllntnya' ... -�.e—\U"IF �.O 1. : I�u�t•�J�"M. lw.�n.u.� upludmiq!~ "M ei+tlK". UNITED STATES POSTAL SERVICE `" .n ri�st- �fil�" . 4 A u ..:5Y4 .�\�a ♦auo-�.lo� • Sender: Please print your name, address, and ZIP+4 in this box • I I I I I Town of Barnstable ! I t 4 Health Division 200 Main Street C Hyannis,MA 02601 I I � I I :� ' Health Master Detail Page 1 of 1 ,w ,} wry.W5.,..tJ- ....:s .'a'».t s Detaily„ iS iO4' i . �. `ewi (.'vl i3. Parcel Septic ; Per c V �--i Fuel Tank Parcel: 189-079 Location: 16 SYLVIA LANE, C NT R IL.LE Owner: BAL, MATSVEI & Business name: Business phone: Rental property: Fi Deed restricted .i Number of bedrooms :F 01 Contaminant released: F Fuel storage tank permit: i Save Parcel Chariges Return to Looku Parcel Info, Parcel ID: 1.89-079 Developer lot: 1..OT 3 Location: 16 SYLVIA LANE Primary frontage: 105 Secondary road: Secondary frontage: Village:CEN-ERVILLE Fire district:C.0 MM Sewer acct: Road index: 1680 Asbuilt Septic Scan: 1I39079 1 Interactive map: 3 W, Town zone of contribution:AP (Aquifer Prot:echon Overlay District) State zone of contribution:OUT C,jvner Info Owner: BAL, MAISVEI & Co-Owner:.KA€OLKA, A._IAKSA Streetl:606 OLD STAGE RD Street2: City:CEN"I ERVILLE State: MA Zip: 02632 Ci Deed date: 1/31;2001 Deed reference: 21741/252 Land Info . Acres: 0.28 Use: Single Faai DL-01 Zoning:RD-1 Neighborhood: Topography: Road: Utilities: Location: . Construction Info&U is i't:� `QF` -�F_siit� ecil e =*ae"r=cr0CC;'S t athruo`,'s 1 11965 11715edr0 omsl Full + 1H Buildings value:$151,400,00 Extra features: $8,200.00 Land value: 1183d300.00 http://issql/Intranet/healthMaster/HealthMasterDetail.aspx?ID=189079 8/20/2008 k,S �. hha:, �� E' ,�I '' ���ii` ,�¢,�:. ,., ����1 t {��Y �ina; ,i�: g'�a' �ii'S!( � r. 1_ — � fid t y,� 1�' A's Town of Barnstable of Regulatory Services THE 7 a �P` o Thomas F. Geiler, Directorw � x " Public Health Division * BABNSCABLE, 9 MASS. Thomas McKean, Director 1639. 10 Clt} ArFp �a 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508=790-6304 September 10, 2008 Aliaksa Kadolka 606 Old Stage Road ' Centerville, MA 02632 r As of October 1, 2006 a new rental registration ordinance was put into affect requiring all property owners of rental units to register their rental units with the Town of Barnstable Health Division. According to our records, you own the rental property at 16 Sylvia Lane, Centerville. Enclosed is an application. Please use a separate application for each rental unit you own. Should you need more applications, 9 they are available online at www.town.barnstabl.e.ma.us. Go to the Health Division page by looking in the Department Menu. There is a link to the Rental Registration information on the Health Division page. You may print out as many as you need, and return them to the Health Division with the appropriate 2008 fees included. Failure to comply with this ordinance will result in the issuance of a non-criminal ticket citation in the amount of$160. Each day of non-compliance is considered a separate offense. 1` Should you'have any questions, please feel free to call 508-862-4644. Thank you in advance for your cooperation. Timothy B. O' onnell Health Inspector Health Division Direct #508-862-4646 J � � � ��� ,9� a ' g9 (��j 'J Bk 23168 p9206 049331 MASSACHUSETTS QUITCLAIM DEED We,Matsvei Bal and Aliaksandr Kadolka,of 16 Sylvia Lane, Centerville,Massachusetts 02632, for consideration paid,and in full consideration of ONE AND 00/100 Dollars(U.S. $1.00)grant to Matsvei Bal,Individually,of 16 Sylvia Lane,Centerville,Massachusetts 02632 with quitclaim covenants the following property in Barnstable County,Massachusetts. Property Address: 16 Sylvia Lane Centerville MA 02632 EXHIBIT"A" The land with the buildings thereon in Barnstable(Centerville),Barnstable County,Massachusetts: SOUTHWESTERLY by Sylvia Lane,one hundred five and 03/100(105.03)feet; NORTHWESTERLY by Lot 2, Block `B", as shown on a plan hereinafter mentioned, one hundred seventeen and 21/100(117.21)feet; NORTHEASTERLY by land now or formerly of Joseph Daggett, et als, as shown on said plan, one hundred five(105)feet;and SOUTHEASTERLY by Lot 4, Block "B", as shown on said plan, one hundred nineteen and 79/100 (119.79)feet. Containing 12,460 square feet of land, more or less, according to said plan;and being shown as LOT 3, B10CK"B",on a plan entitled,"Subdivision of Land known as `Holly Heights',in Centerville,Barnsatble, Mass. property of Holly-Heights, Incorporated", drawn by Ed Kellogg, Engineer, and recorded in Barnstable County Registry of Deeds as Plan Book 139,Page 153. The above described premises are conveyed subject to a grant of an easement to Cape&Vineyard Electric Co., et al as set forth in an instrument recorded with said Deeds in Book 1047, Page 334; also conveyed to a taking by the Town of Barnstable as set forth in Book 1295,Page 1145. Subject to all rights,rights of way, easements,restrictions and reservations as the same may be in force and applicable. PREPARER OF DEED HAS NOT EXAMINED TITLE Bk 23168 Pg 207 #49331 Witness my/our hand(s)and seal(s)this Pday of September,2008 Matsvei Bal Aliaksandr K"ol Commonwealth of Massachusetts Barnstable,ss: September�$,2008 Then personally appeared the above-named 6 Nkh\(.Scu%d'' (Qd'and probed to me through satisfactory evidence of identification, which were be the person whose name is signed on the document, and acknowledged the foregoing instrument to be his/her/their free act and deed before me. lvo a, Notary Public, My Commission Expires: • f ' � PROPERTY ADDRESS: 16 Sylvia Lane, Centerville MA 02632 ,••' OA. ; "o'� S may• ICC"Mown"OF BARNSTABLE REGISTRY OF DEEDS I Certified Mail#7006 2150 0002 1042 0514 �aFj Town of Barnstable P ti Regulatory Services 1 r BARNSCASM �\v MAS& Thomas F. Geiler, Director 'AMA Public Health Division Thomas McKean, Director, s 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 20, 2008 Aliaksa Kadolka 606 Old Stage Road Centerville. MA 02632 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION, THE STATE ENVIRONMENTAL CODE, TITLE 5. The property owned by you located at 16 Sylvia Lane, Centerville MA was inspected on August 14, 2008 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint. The following violations of.the State Sanitary Code were observed: 105 CMR 410.300 and 310 CMR 15.00: There were a total of six (6) bedrooms observed in this dwelling; one (1) was observed in rear apartment, three(3)were observed on first floor of main house, and (2) two were observed within the basement. However, the existing septic system (permit# 96-67) was not designed for(6) six bedrooms. It was designed for three (3) bedrooms. You are ordered to correct the violations listed above within fourteen (14) days of your receipt of this notice by pulling any required building permits (if applicable); - You are ordered to remove any (3) three bedrooms from this home by removing entrance doors and by opening all.door-way entrances to each room in the basement to minimum of five feet wide openings. This will bring the total bedroom count down from (6) six to the appropriate (4) four as designated by your septic permit. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance ill result in a fine of $100.00 per violation. Each day's failure to comply with an ord shall constitute a separate violation. Thomas A. McKean, R.S., CHO QA0rder letters\Housing violations\Rental ordinance\24 alberti way cent. FORM30 C&w Hons&WARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD�O�HE AI..T[-I CITY/TOWN DEPARTMENTA ADDRESS GSM s0``0� TELEPHONE / Address �� 54ojA� Ynw- — Occupan 4, 1 1 1 Floor Apartment Igo. No.of Occupants No.of Habitable Rooms__No.Sleeping Rooms No.dwelling or rooming units_ No.S o Lies Name and address of owner Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish l Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: -0 Roof " Gutters, Drains: ^� Walls: Foundation-,- Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n..- Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room _ Bedroom 1 9 Vtl 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 R ORT S SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PER INSPECTOR TITLE A.M. DATE—A' I q ®� 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 those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR.410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) 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 - An other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750 A through O shall be deemed to be O Y � ) 9 ( ) 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. ems ,,,..,-.y,.,"1 .-f� _.-.n n,-.ry'+.-..'Y _ .,f..M •r ,,.7' �..! t,.. .. �i.^ ,; . +..M.�.. wLr r.�J/"+._..}1"b""_, f tt FORM,30 C&W HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS ,s B O A R D�0�FAH E �..H . r r • � � y U CITY/TOWN V � t � DEPARTMENT ADDRESS j TELEPHONE Address , , �l �,�,.ti,..... '`�°"� — Occupant_-��'' t Floor Apartment No. No.of Occupants No. of Habitable Rooms_d_No.Sleeping Rooms CSC No.dwelling or rooming units No.Stories Name and address of owner ' t CP nA AllmRemarks Reg. Vio. YARD Out Bld s.: Fences: s Garbage and Rubbish — Containers: I Infestation Rats or other: /. STRUCTURE EXT. Steps,Stairs,Porches: r 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: , Hall Windows: c HEATING Chimneys: Central;_❑ Y-, �] N . E ui :.Rep air_: .j_ TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: S ❑ 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 w i Bathroom / tIn Pant f 1 __`L UIV. L Den r Y lot r Living Room 'F k out- Bedroom 1 4SWV11VC, Bedroom 2 j Bedroom 3 .'s fir i 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 r Rats, Mice, Roaches or Other`. Egress Dual and Obst'n: General I 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 'i OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION RERORT S SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR TITLE -,"j ,E U A.M. DATE � 14 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 those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) 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. ..n. ,.,-- 's-:� T.Q.Y.• w r. r'-' - •.+.. ...♦.. v . s r r m • • { .�, FORM30r CAW HOBBSB WARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN ' u 4 DEPARTMENT a , I r� ADDRESS f TELEPHONE Address ' r ,ram — Occupant � .G = Floor Apartment No. No.of Occupants 7 No.of Habitable Rooms b No.Sleeping Rooms '5 No. dwelling or rooming units_ No.Stories t Name and address of owner f,,-,/," Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: As,Drainage Infestation Rats or other: '`" STRUCTURE EXT. Steps,Stairs, Porches.- Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof A ,w-sf Gutters, Drains: f. Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: .Dampness: /Stairs: Lighting: STRUCTURE INT. / Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: .Central<- ❑ Y; -❑ N E ui .Repair .- TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L tn' . Outlets Walls Ceils. . Wind. Doors Floors Locks Kitchen BathroomA A Pantry k Den Living Room , ? '.,7t, L' Bedroom 1 , 96 Bedroom 2 %r 6 Bedroom 3 1 P s5 ' 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.: -r Wash Basin,Shower or-Tpt�:- = y 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 PER.U,RI INSPECTOR TITLE_Ick,)� ""f . � A.M. DATE A." 14 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 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 ever case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that Y 9 Y other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450,410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. public Health Uivision •` �,w,wts� 7��kX �, ��,,. r�o�l w,,,R,,,,s�,�usn Town of Barnstable t.✓ ,.I�s r-y'�+�vsxc"�Ye�(�cltrv� � INfe�.4la.>`fl ar � a�l co�►�te4�cfor� PO Box 534 •�A�-�st � 1'•C'Pi�orlWteJ�GsItrIB� �i4Lt- I.f{�gflo�5 o6f)rRMI�`D 'DY Hyannis,Massachusetts 02601 U�w.Yt.u,�+� H �'fo>5>g:t:G's Z'G• G�lou�. crl 5j�g4C.,p(inJ�- '3Y � � vltOP - Fax(508)775-3344 Phone 508)790-6265 ' I — — — — — — — — — — — — — — — — —I I Toi.l ✓G S.f�^� t.�t. I I fc II Onf 441 ! eot,1 -tea 4<.EwfEtJ( — —u — — — I I ) I M _•� 0± 3•�0 <. sly =1 I !r''ICJ G�G' G'- 7%�� •nicer.�-+�2"fa.✓� 1 :rrs t Y t r t "+Ta • = --- , 1 I - - - - 4, . Ar oa'-oe vre I" . •� - f�Ir.lG'�c�lr'd!�'�'t of 1.�2�os7 - ,Oo� i 1 I`� a L viNG, g � -- IDN 2Z � � 4 � —67 Co o � r AUAO- i PLO O'P- �S�y�Q\Rt fpej a ree UV tOG t. 0 to` Li rn AREA:= �1 I io I� oF�iGE �kW R C_ 2) gao� 22 Ll PLI 6 ` r �,E�ROOM �Loo LW E u 'c o _ YF' L AC,& tj-T-t�?,vl lie, r 1 I 4 22 �M 6 � 41 0 N FAMILY �1 �oRAG� LOWEZ C)�z NG, I I � OFFICIAL � Postage $ �OS Q? ru Certified Fee O Return Receipt Fee Postmar{� �oo� O (Endorsement Required) Jaeff y O Restricted Delivery Fee O (Endorsement Required)Ln ri Total Postage&Fees $ a l v V`SPS ru o fi VeJ.�a.J-._�-ia�k5a,�dr �'c Ida!kac_....... p Street,ApL No.; No.' or PO Box` IP+4 - u Z d � -old ---------- ----------------------- City State, IP+4 V'I ( r\-?r- V V /I Certified Mail Provides: a A mailing receipt a A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: a Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. a Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If,a postmark on the Certified Mail receipt.is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 i SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete A Signature item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. $, Recei y(Printed Name) C. ate of Delivery ■ Attach this card to the back of the mailpiece, t-e1 C,�� �f or on the front if space permits. S wG D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No Vl�Ia�SJcI ►3aI AI(dbaodr KOIdvlKA ?te_ O(dj�p (k 3. S)rv3ce Type Cch-f,C v V r h V�O A egiifled Mail ❑Express Marl ❑Registered ❑Return Receipt for Merchandise � ❑Insured Mail ❑C.O.D. 2-1 4. Restricted Delivery?(Extra Fee) ❑ z. Article Number 7 0r0 6: 215 0 0002 10 4 21 ] 1`6 0 i (Transfer from service label) PS Form 3811,February 2004 Domestic Return Receipt '. d: tsito' i UNITED STATE LG&W&EI''a pt 4 • Sender: Please print your name, address, and ZIP+4 in this box • I 4Nea P4. 200 Maio i l r�n�15 VVl q r Certified Mail#70062150000210421160 �tNEE lati Town of Barnstable Regulatory Services g Y IIARNSTABLE. � 9 MASS. g Thomas F. Geiler,Director ��rf0 MA'S A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 9, 2008 Matsvei Bal Aliaksandr Kadolka 16 Sylvia Lane Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION. The property owned by you located at 16 Sylvia Lane, Centerville, was recently denied eligibility to the Town of Barnstable Accessory Affordable Apartment Program on May 30, 2008. Linda Edson from the Building Department has made the Health Department aware of fact that there is (4) four bedrooms in said dwelling. 105 CMR 410.300 and 310 CMR 15.00: There were a total of four (4) bedrooms observed in this dwelling. However, the existing septic system (#97-67) was not designed for four(4)bedrooms. It was designed for three (3)bedrooms. You are ordered to remove (by pulling any permits if applicable); any bedroom from this home by removing entrance doors and by opening all door-way entrances to each room to minimum of five feet wide openings. This will bring the total bedroom count down from (4) four to the appropriate (3) three as designated by our records. You must either complete the above alterations to the bedrooms or up grade the current septic system to represent the current number of bedrooms. Due to the fact you are not within the Zone of Contribution to public water supply wells you are eligible for this second option. This will entitle you to be able to keep the current number of bedrooms. This must be done with proper permits and engineered plans and be completed within sixty(60) days of your receipt of this letter if you choose this option. QAOrder letterMousing violations\Rental ordinance\16 sylvia In.doc You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Timothy O'Connell, Health Inspector Cc: Linda Edson QAOrder letters\Housing violations\Rental ordinance\16 sylvia ln.doc . Town of Barnstable Health Inspector oF1NE tp� Office Hours o Regulatory Services 8:00—9:30 Thomas F.Geiler,Director 3:30—4:30 + MUMSfABLE, Only MILM Public Health Division i679• 10 �fo►�o+a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT QUESTIONNAIRE 1. General Information: Address: 1 to Svu(.& LihiE, aimki uc Map_J-3q Parcel Name: VI)p D u&A Phone: M)� (��Z 2. How many bedrooms exist on your property now? ED U 9- 2a. Please include a copy of your floor plans for the entire property. 3. Is the dwelling connected to public sewer? YES or ONO If the dwelling is connected to public sewer, skip questions 4-9 below. 4. Location of dwelling is INSIDE o O TSID a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO 6a.If yes, how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ---------,�----------------------------------------------------------------------------------------------------------- Lr�-'J FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY The Public Health Division has no objection to 73 bedrooms at this pro erty. a gseoKc S StL*i ..,GS 4S.05ne(Q tO� 3 �deavH.s i1 199 7, ��S�Z�+� �S 1; ����� Signed: L Date: �� L91D9 t^ S,2e Inspector(Print): 'f;' N w•{ti o.J�- Q;/heal th/wpfiles/amnestyapp �� - �� 2 �-/ � �� p THE Tp� The Town of Barnstable Y r Y • BARNSTABLE, 9� MAC.039. Growth Management Department 10 367 Main Street, 3`d Floor Hyannis, MA 02601 Tel:508-862-4678 Fax:508-8624782 March 11, 2008 John C. Klimm, Town Manager Janet Joakim,Town Council President Barnstable Town Hall 367 Main Street Hyannis,MA 02601 Re: Aliaksandr Kadolka and Matsvei Bal, 16 Sylvia Lane, Centerville; one-bedroom accessory unit This letter is to inform you that the Accessory Affordable Apartment (Amnesty) Program has received a request for a project eligibility letter under the Community Development Block Grant (CDBG) Fund and under Article II of Chapter Nine of the Code of the Town of Barnstable and the criteria for the Local Chapter 40B Program. This office is reviewing the request. If the Town has any comments on the project, please forward them to me so that they can be addressed in the site approval letter. This letter gives you official notice of our receipt of the above application(s). We will issue a decision as to the acceptability of the sites and the consistency of this development within the guidelines of CDBG. Sincerely, Elizabeth Dillen Special Projects Coordinator Growth Management Department cc: Building Division Health Division Certified Mail#7006 2150 0002 1041 9013 �afIKE`r, Town of Barnstable ti¢ Regulatory Services 9 MASS. g Thomas F. Geiler, Director ar W M Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 16, 2008 Matsvei Bal Aliaksandr Kadolka 16 Sylvia Lane Centerville, MA 02632 , NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION. The property owned by you located at 16 Sylvia Lane, Centerville, was recently denied eligibility to the Town of Barnstable Accessory Affordable Apartment Program on May 30, 2008. Linda Edson from the Building Department has made the Health Department aware of fact that there is (4) four bedrooms in said dwelling. 105 CMR 410.300 and 310 CMR 15.00: There were a total of four (4) bedrooms observed in this dwelling. However, the existing septic system (#97-67) was not designed for four(4)bedrooms. It was designed for three (3)bedrooms. You are ordered to remove (by pulling any permits if applicable); any bedroom from this home by removing entrance doors and by opening all door-way entrances to each room to minimum of five feet wide openings. This will bring the total bedroom count down from (4) four to the appropriate (3) three as designated by our records. You must either complete the above alterations to the bedrooms or up grade the current septic system to represent the current number of bedrooms. Due to the fact you are not within the Zone of Contribution to public water supply wells you are eligible for this second option. This will entitle you to be able to keep the current number of bedrooms. This must be done with proper permits and engineered plans and be completed within sixty (60) days of your receipt of this letter if you choose this option. QAOrder letters\Housing violations\Rental ordinance\l6 sylvia In.doc Certified Mail#7006 2150 0002 1041 9013 Town of Barnstable a" Regulatory Services 13AI2N,4 ABLE, iv "^`. g Thomas F. Geiler, Director ark°M Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 16, 2008 Matsvei Bal Aliaksandr Kadolka 16 Sylvia Lane Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION. The property owned by you located at 16 Sylvia Lane, Centerville, was recently denied eligibility to the Town of Barnstable Accessory Affordable Apartment Program on May 30, 2008. Linda Edson from the Building Department has made the Health Department aware of fact that there is (4) four bedrooms in said dwelling. 105 CMR 410.300 and 310 CMR 15.00: There were a total of four (4) bedrooms observed in this dwelling. However, the existing septic system (#97-67) was not designed for four(4)bedrooms. It was designed for three (3)bedrooms. You are ordered to remove (by pulling any permits if applicable); any bedroom from this home by removing entrance doors and by opening all door-way entrances to each room to minimum of five feet wide openings. This will bring the total bedroom count down from (4) four to the appropriate (3) three.as'designated by our records. You must either complete the above alterations to the bedrooms or up grade the current septic system to represent the current number of bedrooms. Due to the fact you are not within the Zone of Contribution to public water supply wells you are eligible for this second option. This will entitle you to be able to keep the current number of bedrooms. This must be done with proper permits and engineered plans and be completed within sixty (60) days of your receipt of this letter if you choose this option. QAOrder letters\Housing violations\Rental ordinance\16 sylvia In.doe I���G o fro n./� Ids /� S - I I Town of Barnstable Regulatory Services w BAMSPABLE. MA&& g Thomas F. Geiler,Director 1639.ra,` Building Division Thomas Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4024 Fax: 508-790-6230 June 5, 2008 �J 6 Mr. Aliaksandr Kadolka Mr. Matsvei Bal 16 Sylvia Lane Centerville Ma 02632 Re: Illegal Apartment: 16 Sylvia Lane Centerville Map: 189 Parcel: 079. Enclosed please fins a copy of the letter sent to you by the Assistant Town Manager on behalf of the Town of Barnstable. Based on the letter, you have 30 days to apply for a building permit to remove the illegal apartment and restore the property to a single family home. Failure to do this by July 7, 2008 will result in fines of up to $300.00 per day and court action. Thank you f our attention t is matter. Lin dson Amnesty Apartment Investigator Building Department tHEI The Town of Barnstable 6arnstable P Office of Town Manager AWAmedca CRY + BARNSPAK E, * , MASS* g 367 Main Street, Hyannis MA 02601 1639. www.town.barnstable.ma.us Office: 508-862-4610 2007 Fax: 508-790-6226 Email: John.klimm@town.bamstable.ma.us John C. K1imm, Town Manager May 30, 2008 Aliaksandr Kadolka Matsvei Bal 16 Sylvia Lane Centerville, MA 02632 Reference—A request for site eligibility for accessory unit at a single-family dwelling at 16 Sylvia Lane, Centerville Dear Mr. Bal and Mr. Kadolka: Your application for site eligibility to the Town of Barnstable's Accessory Affordable Apartment Program has been reviewed and was found not to meet the threshold criteria established for the program. The property does not meet the Town Manager's Criteria for the Local Chapter 40B Program eligibility requirement that the property be "consistent with the character of the neighborhood with such issues as landscaping and parking" due to the number of lodgers residing in the principal dwelling. The property has been the subject of complaints due to adverse neighborhood impacts. The Building Division will be notified of this denial and will be contacting you regarding enforcement of the zoning ordinance. Sincerely, Thomas Lynch Assistant Town Manager Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. I12 Important: A. General Information When filling out f --0/7 forms on the 7 computer,use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. ECo-Tech Environmental Company Name 43 Triangle Circle Company Address /f Sandwich MA 02563 ' N0 City/Town State Zip Code 508 364-0894 Pending Telephone Number License Number B. Certification 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 Section 15340,of Title 5 (310 CMR 15.000). The system: rW ® Passes ❑ Conditionally Passes ❑ 175-I's ❑ Needs Further Evaluation by the Local Approving Authority r~ cap' December 31, 2006 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Inspector's Note==> Aseptic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 L r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® 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. t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® 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)] t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n1a Number of bedrooms (actual): 4(assessor's) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 170 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 1 year ago Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe): t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts V. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for _ , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner's agent Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ® Single cesspool) (Abandoned) ❑ 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 installed (if known) and source of information: Age: 9+years. Certificate of Compliance issued 2121197(Board of Health permit#97-67) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1.5feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): Depth below grade: 0.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------- Dimensions: 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 15 in Distance from top of sludge to bottom of outlet tee or baffle 19 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? As built card t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 16 Sylvia Lane _ Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended at this time and maintenance pumping is recommended every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of Scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2528.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At 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.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Cover was found to be cracked and was replaced. Pump Chamber (locate on site plan): Pumps in working order: Yes[] No Alarms in working order: ❑ Yes ❑ No t5-2528.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leaching gallery. t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration I(Abandoned) 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.): An intact laundry cesspool exists, but no hookup is currently in place. Do not reconnect any source of wastewater to this cesspool. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is required for Centerville MA 02632 December 31 2006 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. LOCATIONS A B LEACHING 1 15..5 f t 3? f t 9 GALLERY 2 27 F E 43 F E 3 38 Ft 58 FE 4 13.5 f t 16.5 Ft ABANDONED CESSPOOL Zo O-BOX (,CESSPOOL DO NOT RECONNECT no SEPTIC B TANK EXISTING A DWELLING # 16 W _Z J W H Q 3 S Y L_ V I A ROAD NOT TO SCALE t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Sylvia Lane Property Address Ralph and Susan Golding Owner Owner's Name information is Centerville MA 02632 December 31 2006 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 20 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: GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is 20 feet above groundwater table. t5-2528.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 LTV I�� , s �o \2 o 2Z a- 4 s Li R NA�� r (=l � tlEbRoor-4 1 I U9 C-4 u -O(m ` ACE = ��0 . l0 Liar j' E �2 , lotI� i I � �:yL� � , N)TLRV lie, 22 ��M 6i 4i Q O LOOS POo m 2l� 3 STO'RAG�" LO W EI Z LW PLACE- 4�E IL uVTt�G, (01 AsBuilt Page 1 of 1 0 TOWN OF BARNSTABLE LOCATION I :5 11, SEWAGE # VILLAGE Ce ASSESSOR'S MAP&1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACTTY I SCE lg� LEACHING FACILITY: (type) _T YX (size) NO.OF BEDROOMS 3 y BUILDER OR OWNER PERMiTDATE: [_—13 - al COMPLIANCE DATE:C Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility If any wells exist on site or within 200 feet of leaching facility) _ Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Fumished by w r 1 I. L. i J.) http://issgl/intranet/propdata/prebuilt.aspx?mappar=189079&seq=1 3/11/2008 r TOWN OF BARNSTABLE POCATION jay lV iti SEWAGE # 7 VELLA ASSESSOR'S MAP &LOT III-G If INSTALLER'S NAME&PHONE NO.SEPTIC TANK TANK CAPACITY 137M Cal LEACHING FACILITY: (type) (size) NO. OF BEDROOMS 3'y BUILDER OR OWNER PERMIT DATE: Z—11 - !?- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1 a M 1A ,� r No. 7_1,1 7 Fee $5 0 .0 0 THE COMMONWEALTH OF MASSACHUSETTSi Entered in computer: Yes PUBLIC HEALTH DIVISION .,.TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Mi. ppaal *pftem Construction Vermit Application for a Permit to Construct( /Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 16 Sylvia Lane Owner's Name,Address and Tel.No. Ralph Golding Assessor'sMap/Parcel Centerville, MA 0263 771 —6577 Installer's Name,Address,and Tel.No. 7 7 5—3 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Service PO Box 1039 , Centerville, Ma 0263 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(nq 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) Title 5 Septic repair consisting of 1500 caal Tank, D—Box and 30 ' Leaching ( ( 2— 40 ' x 4 ' x 2 ' leachincl trench) . 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 this Bo d of Heal Signed L Date Application Approved by & Date .2 —fZ,,';0 Application Disapproved for the following reasons Permit No. 7 Date Issued -2.- 13 No. _ G 7 Fee $5 0.0 0 as �'b THE COMMONWEALTH OF MASSACHUSETTS :, %' Entered in computer: Yes PUBLIC HEALTH DIVISION -,T01�fIN OF BARNSTABLE., MASSACHUSETTS ­�2p.prication for Migogal 6potem Construction Permit Application for a Permit to Construct( /Repair(X)Upgrade( )Abandon( ) El Complete System .❑Individual Components Location Address or Lot No. 16 Sylvia Lane Owner's Name,Address and Tel.No. Ralph Golding Assessor's Centerville, MA 0263 . 771-6577 Installer's Name,Address,and Tel.No. 77 rj—8 7 7 6 � Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Service PO Mox 1089, Centerville, Ma 0263 Type of Building: d Dwelling No.of Bedrooms 31 Lot Size g l sq.ft. Garbage Grinder(nc Other Tp°eof Building No.-Of-Persons i'I Showers( ) Cafeteria( ) Other Fixtures j K7 ,*-- Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank —Type,of S.A.S. r Descriptiotr_of Soil sand _3 re Nature of Re airs or Alterations Title 5 Septic air consisting �(Answer when applicable) P P g �. of 150$ al Tarok, D-Box and 80 ' Leaching ( (2- 40 ' x 4' x 2' leaching trench) . Date last inspected: l; Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system g 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 Bo d of Heal Signed Gi Date o2' Application Approved by Date 2'"'Z-L J l"1-) Application Disapproved for the following reasons 100, Permit No.,, 7 Dve Issued 13 ,9 � r..+.,,_Lk"''���-"`-'=-''rE✓ .' �_.�l S f yr.THE COMMONWEALTH OF MASSACHUSETTS Golding BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(• ) Repaired (X )Upgraded( ) Abandoned( )by Wm E Robinson Sr Septic Sertice at 16 S*lvia Lane, Centerville, MA has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. -G 7 dated Installer Wm E Robinson Sr Septic Srv.Designer i The issuance of this permit shall not be construed as a guarantee that the syste it function as designed. Date _ ( 517 Inspector t i ————— /———————————————— ——— — —— — —— No. 9—, 7 ly 7 —. -- -- — —Fee $:5:0.00 THE COMMONWEALTH OF MASSACHUSETTS Golding {PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS ' Migogar 6p.5tem Conotructiou Permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 16 Sylvia Lane, Centerville NSA y Wm E Robinson Sr Septic Srv. i and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. I, Date: �' l� 7 Approved by J L'O C K T ION SEWAGE PERMIT NO. /6 E X4 L11A e AL, VILLAGE I N S T A LLER'S NAME & ADDRESS d U I L D E R OR OWNS DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED r ti L. �,fAV NOTICE: This form is to be used for the repair of failed septic systrans only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I,William E. Robinson, Sr.-,hereby certify that the application for disposal works construction permit signed by me dated A-/3-q 1 concerning the property located at 16 Sylvia Lane, Centerville, NU meets all of the following criteria: * There are no wetlands within 300 feet of the proposed septic system. * There are no private wells within 150 feet of the proposed septic system. * The obseved groundwater table is 14 feet or greater below the bottom of the leaching facility. * There is no increase in flow and/or change in use proposed. * There are no variances requested or needed. SIGNED: z ., __ DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification plot plan,this plan should be submitted). 1 1--� ,i�� --- � �� � / . � � �� ��� i �^ � � � � - .. ., .._ ._ . i