HomeMy WebLinkAbout0058 VINE AVENUE - Health 58 Vine Avenue, Centerville
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Town of Barnstable
�pP YHE TOk'1/
Regulatory Services
BARN-STABLE, • Thomas F. Geiler,Director
T Gp MASS.
iGgq, g` public Health Division`g
pTEb MAI A
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
June 7, 2007
Attn: COMM Fire
Health Inspector Meredith E. Morgan conducted a rental inspection in accordance with
Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary
Code, 105 CMR 410.482, the Health Department is required to notify the Fire
Department if there is a smoke detector violation, or possible smoke detector violation.
The following property had possible smoke detector(and\or CO detector) violation(s):
58 Vine Ave. Centerville Assessors Map-Parcel: (226-038):
CO detectors lacking throughout home. Property currently not occupied.
Mere'dit . Morgan -Health Inspector
Q:\Order letters\Housing violations\Rental ordinance\\Fire ViolationsTIRE TEMPLATE.doc
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FORM30 CH�w HOBBS&WARRENrn THE COMMONWEALTH OF MASSACHUSETTS
BO D OF HEALTH
CI T11OW
W f
a E ARTMENT
M TELEPHONE
Address 59 V ii7p A)f• ® y�r` —Occupant
Floor Apart No. No.of Occu s ,
No.of Habitable Rooms__No.Sleeping Rooms
No.dwelling or rooming units. No. ri s_,___�.
Name and address of owner I ffl
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers.-
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness: o
Stairs:
Li htin :
WO
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows: ]
HEATING Chimneys:
Central 41Y N Equip. Repair K)iwlZ '
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
O MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.:
Stacks, Flues Vents,Safeties:
Kitchen Facilities Sink D
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENAL JU Y."
INSPECTOR TITLE
j A.M.
DATE TIME
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 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 Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
I
FORM 3O
W Hoeesa WnaaevTM THE COMMONWEALTH OF MASSACHUSETTS
BOA, D OF HEALTH
CITY/TOWN
W 1 I
o ^
DEPARTMENT
ADDRESS
M eye ` V TELEPHONE
Address Y �1,)�-1C x.0—D.ltT�'N1)1'Q jige
cupan
j Floor Apart t No. No.of Occs
j No.of Habitable Rooms_No.Sleeping Rooms
No.dwelling or rooming units No. ri.s ,/
Name and address of owner i P • Y
_ Remarks Reg. Vio. "
! YARD Out Bld s.: Fences: '
i Garbage and Rubbish
Containers:
Drainage "
Infestation Rats or other:
f
STRUCTURE EXT.` Steps,Stairs, Porches:
I Dual Egress:and Obst'n.:
f ❑ B ❑ F ❑ M Doors,Windows:
Roof
1
i Gutters, Drains:
Walls: ~�
Foundation:
Chimney:
f BASEMENT Gen.Sanitation:
Dampness:
j Stairs: % (f,
von
S d
I Li htin : ( I
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting: ,
Hall Windows -S 101'� AJ9-,' I�
HEATING Chimneys: VM 10flr k1_ h G x /,
Central Y N Equip. Repair KJ iW iAj f
TYPE: Stacks, Flues,Vents: pot,M bo it
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:
i Gen. Basement Wiring:
DWELLING UNIT
Ventil. L tp'.. Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
I Pantry
Den
—Living Room
Bedroom 1 -
f
Bedroom 2
Bedroom 3
j Bedroom 4
,Hot Water Facil. Sup.Ten.,Gas, Oil, Elec1.—
" ~ Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
I Wash Basin,Shower or Tub: !
Infestation Rats, Mice, Roaches or Other: /
Egress Dual and Obst'n:
General Building Posted
Locks on Doors: i
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-PE JURY." /INSPECTOR TITLE ��il ' Z C /C,/
A.M.
DATE _ 4 D" " 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.
Town of Barnstable
o� Regulatory Services
t nARNMOLE. Thomas F. Geiler,Director
�Ar o Mn�a
9 Public. Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
June 7, 2007
Attn: COMM Fire
Health Inspector Meredith E. Morgan conducted a rental inspection in accordance with
Chapter 170 of the Town of Barnstable Code. In accordance with the- State Sanitary
Code, 105 CMR 410,482, the Health Department is required to notify the Fire
Department if there is a smoke detector violation, or possible smoke detector violation.
The following property had possible smoke detector(and\or CO detector)violation(s):
58 Vine Ave.Centerville Assessors Ma -Parcel: 226-038 :
CO detectors lacking throughout home. Property currently not occupied.
c?ooa -T19-C - 06-la- 0--7
Mer dit . Morgan- ealth.Inspector
Q:\Order letters\Housing violadons\Rwtai ordinance\\Fire ViolationsTME TEN2LATI340c
Eiz'd T L0'ON Hi-Id3H 30 GdU09 TIEUiSWdUg WdOZ:E L002'L 'Nnf
COMM Fire District
1875 Route 28
CENTERVILLE, MA 02632
1926
INSPECTION REPORT
Friday June 22, 2007
DEYTON, EDWARD
58 VINE AV
CENTERVILLE, NA 02632
Occupancy ID: DEYT01
Date Completed: 06/19/2007
Inspection Type: INSPECTION - Follow-up
Follow up with housing inspection report of no CO detection in the residence. Mr. Ed
Deyton called stating that there is 8 CO detectors in the residence and Vivian Real
Estate is the property manager for the building. Called Vivian Real Estate to
schedule a time for follow up. Will meet AL at 15:00 hours on 06-19-07
Vivian Real Estate 508-775-0158
Owner: Ed Deyton: 978-409-1105
06/18/2007 09:34:31 fpulsifer
Inspected home this date, CO detectors have been added in home, however 3 locations
have doors separating CO detector from bedroom being covered. Three battery operated
CO detectors to be added 1st floor hallway outside bedroom, 2nd floor hall outside
bedroom, 3rd floor hall outside bedroom. Replaced plug in CO detector in basement
without battery back-up with CO detector with battery back-up.
Call for reinspection
06/20/2007 09:53:54 mmacneely
06/22/2007 12:43 Page 1
r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
i = C DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617.292.5500
WILLIAM F.WELD TRUDY COM
Governor Secretar
ARGEO PAUL CELLUCCI DAVID B STRUFf
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 8 Commissionc
PART A r
CERTIFICATION
Property Address: 58 Vine Ave Craigville ,MAss Address of Owner: 40 RZCE10 1106
Date of Inspection:647/97 (If different) JU� Jr Name of Inspector: ,hsepli P-Macomber JR.
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 00) V1hVpp 1997 r„
Company Name: J.P.Macomber & Son Inc . Hfaj�Ao PjrAecf N
Mailing Address: BOX Centerville ,Mass . 02632
Telephone Number: 508_775--3,338 A '4,
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date:
The System Inspector all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow,of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, Or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
,V4C One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Pago 1 of 10
DEP on the World Wde Web: http:/lwww.magnet.state.ma.us/dep
0 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 58 Vine Ave Craigville ,Mass .
Owner: Charles Sangree
Date of Inspection: 647/97
B] SYSTEM CONDITIONALLY PASSES (continued)
AO Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
kP Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
�Q 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
�i The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance otlA (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 58 Vine Ave Craigville ,Mass .
Owner: Charles Sangree
Date of Inspection:617/9'7
D) SYSTEM FAILS:
You must indicate ei;!:er "Yes" or "No" as to each of the following:
A)b_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303, The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid leve,�hth�disribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in-ees6pe�e/l�is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
_ . The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
_A* _ the system is within 400 feet of a surface drinking water supply
_ )k _ the system is within 200 feet of a tributary to a surface drinking water supply
_ A)A _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 58 Vine Ave Craigville ,Mass .
Owner: Charles Sangree
Date of Inspection: 647/97
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
— None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
— The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
— The site was inspected for signs of breakout.
/ All system components, owl uding the Soil Absorption System, have been located on the site.
�L The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
— Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 58 Vine Ave Craigville ,Mass .
Owner: Charles Sangree
Date of Inspection:617/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow:�ibg.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):_4Q
Laundry connected to system (yes or no):2LJ 5
Seasonal use (yes or no): C
Water meter readings, if available (last two (2) year usage (gpd): /ft5l-
Sump Pump (yes or no): 111'(1b Xa: 00 0A44v$=`'7.
Last date of occupancy:'//
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: a gallons/day
Grease trap present: (yes or no)&i
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)W
Water meter readings, if available: 44
LIA
Last date of occupancy: 10
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING ORD and so rce�f i ormation: /
7 i ,� 6�Jr Y
System pumped as part of inspection: (yes or no)
If yes, volume pumped: Ions >�
Reason for pumping: ' Q/�yy'-
TYPE SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
ZJ6 Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
4 I/A Technology etc. Copy of up to date contract?
Other �A
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)ly
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 58 Vine Ave Craigville ,Mass .
Owner: Charles Sangree
Date of Inspection:6/17/97
BUILDING SEWER:
(Locate on site plan)
Depth below grade: iJ
Material of construction: _cast iron _40 PVC other (explain)
Distance from private water supply well or suction line , VIA
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
All joints are tight: No Signs of leakagpo System is vented through the
glib'n t
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age Al Is age confirmed by Certificate of
Compliance 4LI- (Yes/No)
Dimensions: M', 1"4 le t ' JV"44a1L V"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:_
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: 6& 41% UZ 42z, }
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) tank ev ry 2-3 years : Tnlet & outlet tees
are in place : Liqui eve at outiet is : Septic tank is structurally
sound! No evidence of leakage Tank cover on the irtlpt of tank glijild _
b era-i-s-ed i s 1 i t.h.i.n-611 . of ,,-,d.,-.Tank cover on the outlet end of t h e
septic tank.must be raised. It is ander the asphalt driveway. Must have a
GREASE TRAP: 11&1!� cast iron ring & cover to grade .
(locate on site plan)
Depth below grade: 41W
Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain)
,(Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 1/9
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: Z-1
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
Grease trap is not present
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 58 Vine Ave Crai.gville ,Mass .
s ree
Charles San
Owner: g
Date of Inspection: 6/t7/97
TIGHT OR HOLDING TANK:A,&'f(Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction:Algoncrete _metal _Fiberglass _Polyethylene _other(explain)
A IA-
-IyA
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order _ Yes; _ No
Date of previous pumping: _
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
'Eight or KoiUing tanks are not present.
DISTRIBUTION BOX:Z/
(locate on site plan)
Depth of liquid level above outlet invert:_/,/2)
Comments:
(note if level and distribution is equal, evidence of solids arryover, evident of leakag into rout of Oo , etc.)
Distribution box is level and has '.two �latera�ls :I�o evidence of so icls
carry over.-No evidence of leakage in or out oi the distribution box.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: (Yes or No)J&114-
Alarms in working order (Yes or No)—"
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Pump chamber is not present
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 58 Vine Ave Craigville Mass .
Owner: Charles Sangree
Date of Inspection:6/07/97
SOIL ABSORPTION SYSTEM (SAS):z
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: b ,�l/-" �' 41( -r)4"L fl 2 'frB�.
leaching pits, number:6 g— � 6D0 �j' .vs
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dime lions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note c ndition of soil, sigh of hydraulic failure, level of ponding, condition of vegetation, etc.)
See Page 1 U� (rovers on the two 1 Panhi ng Z i t.c arP /t t hal nw arnriP ThPv
n
or ponding: :Ail vegetation is nor a .
CESSPOOLS: "16
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: AM
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Cesspools are notVlfresent
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
esspoo s are not present
PRIVY: I e-
(locate on site plan)
Materials of construction:_ / 10 Dimensions:
Depth of solids: 414
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Privy is not present
(revimed 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 58 Vine Ave Craigville ,Mass .
Owner: Charles Sangree
Date of Inspection:6/17/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
_per O
irr
---- ,J V%t/P All
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISK SYSTEM INSPECTION FORM
C
SYSTEM INFO ION (continued)
Property Address: 58 Vine Ave Craigville ,Mass .
Owner: Charles Sangree
Date of Inspection:6//7/97
Depth to Groundwater ZL Feet
Please indicate all the methods used to determine High Groundwa Nation:
--Z/obcained from Design Plans on record
Observation of Site (Abutting property, observation hole, ba ; sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groun Elevation. (Must be completed)
ESTABLISHED HIGH WATER BY PLANS DRAWN ON 12/21 /78/ See Page 10A
3�
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t
(revimed 04/25/97) Pa of 10
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I TOWN OF Barnstable BOARD OF IIEALTII
SU113URFAU SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
� h-•T„-r••.-•.,.—r..a-.-r�v�n+n•Rn.,.,.r,.•....+.T„.--.,.,e..R..r.r...-•-.•...+...u..n..�..,.r. .,,, ,-,.-
-TYPL OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 58 Vine Ave Craigville ,Mass . '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Charles Sangree
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Sow Inc .
COMPANY ADDRESS Box 66 CentervillemMass . 02632.
Street Town or City Sta O ZjI
COMPANY TELEPHONE ( 5ns ) 775 3338 FAX (508 790 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system
this address and that the information reported is true , accurate , and
complete as of the time of .inspection - The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
With my training and experience in the proper function and maintenance of o
site sewage disposal systems .
Check one :
XXXXXXXXXXXXXSysteui PASSED ,
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
liealLh or the environment as defined' in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con cted has found that the system fails t
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or" "Perator shall upgrade *
he eyete
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 16 , 306 .
partd . doc
w
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualificatigns as required and is hereby
authorized to use the title
CER'I`EMD TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the ' ion of Water Pollution Control
TOWN OF BARNSTABLE
'LOCATION r✓' p SEWAGE #
srII,LAGE / ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACIL=: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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 17�a.ck rit P�P�t/ Cd�x,b��7�y7
s
v\
CS 27
O O
-7
LOCATION SEWAGE PERMIT NO.
-VILLAGE
INS,TA LLER'S NAME i ADDRESS
I U I L 0 E R OR OWNER
G
DATE PERMIT ISSUED 411
DAT E COMPLIANCE ISSUED
FZ
-7
L5 ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARDBO
m..' EALT
............. GZ_%......OF.......
Appliration for Bi-spooal Workii Tonstrurtion ramit
Application is hereby made for a Permit to Construct (y<) or Repair an Individual Sewage Disposal
System at: P, Avr Vli-
N. .................................................. ..................................................................................................
Location-Address Z', or Lot No.
..............�YAe;E!F! ............................................ ...............................................
Owner Address
AL
................ .......::................................................ ..................................................................................................
............. E
Installer Address
U Type of Building Size Lot............................Sq. feet
)--4 Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder (K
Other—Type of Building No. of persons............................ Showers Cafeteria
Otherfixtures ......................... ............................................................................................................................
7_Design Flow................ ...................gallons per person per day. Total daily flow__.___..... ....... .....gallons.
....
IY4 Septic Tank 4Liquid capacity./$-Wgallons Length................ Width_............... Diameter..._........_._. Depth................
Disposal Trench—No. .................... Width............._...... Total Length......_..........._ Total leaching area............ sq. f t.
Seepage Pit No ...../............ Diameter........./40----- Depth below inlet...........j/ .... Total leaching area.....��q. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date..............................►........
Test Pit No. 1_--------------minutesperinch Depth of Test Pit--________-___----- Depth to ground water----/AO-------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....._..................
9 ..........-_------------ ...............................
---/ -w .. . .- . ..............................Description of Soil So ------
7.
......... 0,4........top... ... ...............................
------------------------------------- -------- ------------------------------------------------------------------------ ----------_-------------
U Nature —.E when applicable ---------- - - -
U Nature of Repai oYAlte A wer w " p ---- --- -------
..:! A&AA �O
......................... 4 . .....
Wwvw-16,�- ��,'1.0% a---------- .......................*-------
Agreement: 1.
The undersigned agrees to install the aforedescribed Individual age i posal System in accordance with
the provisions of'AI"IZj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boa "f I Ith, I "ea"n,
oo
igned-eo ..... ................................
Application Approved By........... ne -------------- D..............
.......... 91........
Date
Application Disapproved for the following reasons:................................................................................................................
........................................................................................................................................................................................................
Date
PermitNo......................................................... IssuedL.......................................................
Date
-7�
N ................ .. Fns..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O -IEALT
............. 0 :1......OF....... . .. -----
Applira#ion for Disposal Works Tonstrnr#iun Vamit
Application is hereby made.for a Permit to Construct (V<) or Repair ( ) an Individual Sewage Disposal
System at
.. ......................V
.�l...................................................................................................
Location-Ad res or Lot No.
Owner Address
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (1( )
Other—Type of Building lv _t 1xG__ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ..............................................•-----..-•-•••------•--•---•---•-----•----•-----•----•-----•----••-----------•--------......_......
W Design Flow.:ff_____________ _55 ..................gallons per person per day. Total daily flow----------- _ C ... ........gallons.
WSeptic Tank--l-Liquid capacity./_5_ 4allons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length............ Total leaching area............�.,....3 sq. ft.
Seepage Pit No
.......�-........... Diameter.........,��i_.__. Depth below inlet........... ..... Total leaching area.._.._!.?...sq. ft.
Z Other Distribution box ( ) . Dosing tank ( )
Percolation Test Results Performed by............................................................................ Date............................_.A........
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water... �.._...........
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a w r ----
Description of So>1. ", l,/ �"". ....., �r`� t r .drC IJ {�f's 1� -----------------
�.�
w ✓ .... .. ,. t -------------
.......................... ,r
U Nature of Repai o Alter ns-Af1'wer when pplicable ...................... ..: ;_-______ ._.
fl = #�1... _00----_� --• -----------------------------
Agreement:
j`y U � 7
The undersigned agrees to install the aforedescribed Individual 7ewage posal System in accordance with
the provisions of TITL L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en issue b the bo i' of ealth.
igne •..................... ........r........... .. ms--•- ..........................-•-------------••-------.._....
Application Approved By... ..._.. ;�rf. . ..... "" �� ��
D
r
Date
Application Disapproved for the following reasons:----•--•-•-•---•------•--•-----------------•-------•--...-----•---------------•-•---•----••-------•••..........
.......................................•------------------------------------------------------------•---------------•-----------•--------•--•-----••--•---•-----•----•-•-•--------------•-•----...------
Date
PermitNo......................................................... Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
........OF........ . ... . ..... ......
-f�rr#i�irtt�e ,v� ft�um�rli�anrr
THI IS T E VFY, T at the idividual Sewage Disposal System constructed ( ) or Repaired ( )
by -
-- .. Installer . ................ .....
has been installed in accordance with the pro�ions of TI F° r of The ate Sanitary Code as descr...ib.ed in the
application for Disposal Works Construction Permit No.,.........
.... dated --=---.� ....---�--- ---------------•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE.............../ ............................................ . ... _ Inspector z?'_r� �'`,' .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
J
6)1
v- OF.........
. FEE. .�..........
13
Permission,is hereby grante ) ._ ...
to Cons t o air an I vldual Sewage DisposU�tem
atNo. +....... ::: .. '.. _. _ --*.............._....•-•----------------•-•--....-•-.........--•--•-•---• ----••---
Street �-
as shown on the application for Disposal Works Construction Permi ___ ::. _ ted.._ '..:}. ........
Board of Health
DATE-• � .:..��r
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
6p4XBA(.L CAD
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