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=� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 18 Hi Ona Hill Rd
Property Address
CYO\rJ�S
Owner Owner's Name
information is
required for every Centerville Ma 4/12/14
page. Citylrown State Zp Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Chad Hathaway
use the return
key. Name of Inspector
H.P.S.
�y Company Name
P.O.Box 151
Company Address
Forestdale Ma 02644
City/Town State Zip Code
774-274-2581 12866
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 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
l 4/12/14
I spector's Si ture Date
The system inspector shall su "mit 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.
t5ins•3113 Title 5 Official Wn ,. n:Subsurface Sewage Disposal System•Page 1 of 17
•i
i
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information is required for every Centerville Ma 4/12/14
page. Cityrrown 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:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
1000 gal tank ing good condition with baffles in place Recommend pumping tankfor maintenance.
Dbox in good condition no leaks or cracks. no signs of backups or ever being overfull
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.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exMtration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
c:.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 18 Hi Ona Hill Rd
Property Address
Owner Owners Name
information is required for every Centerville Ma 4/12/14
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information is Centerville Ma 4/12/14
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
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
El ® 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 Y2 day flow
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
r,
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information is required for every Centerville Ma 4/12/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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
El ❑ 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 18 Hi Ona Hill Rd
Property Address
Owner Owners Name
information is required for every Centerville Ma 4/12/14
page. Cityrrown 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information is required for every Centerville Ma 4/12/14
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
000
to I.�L - `'( I �Do
Sump pump? ❑ Yes ® No
Last date of occupancy: 3 years 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:
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information is required for every Centerville Ma 4/12/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: none
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
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information is Centerville Ma 4/12/14
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
tank unknown Dbox and leaching 1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2,
Depth below grade: feet
Material of construction:
®cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1.5'
Depth below grade: feet
Material of construction:
® concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
4"
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information r ev Centerville Ma 4/12/14
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28
Scum thickness 2
Distance from top of scum to top of outlet tee or baffle 4
Distance from bottom of scum to bottom of outlet tee or baffle
24"
How were dimensions determined? tape and sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 18 Hi Ona Hill Rd
Property Address
Owner Owners Name
information is required for every Centerville Ma 4/12/14
page. Cityi'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.):
tank and baffles are in in good condition no signs of cracks leaks.
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):
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information is Centerville Ma 4/12/14
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
q
Depth of liquid level above outlet invert
0
P
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.):
dbox in good condition no leaks or cracks no staing abov bottom of outlet pipes to indicate past failure
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
inspected through dbox and no inspection ports
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Hi Ona Hill Rd
Property Address
Owner Owners Name
information is required for every Centerville Ma 4/12/14
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 6 infultators 2
rows of 3
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information is required for every Centerville Ma 4/12/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17
a
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w ' 18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information is required for every Centerville Ma 4/12/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Lj
/0 31
0 /s
2) Q
t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 15 of 17
i
R
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Hi Ona Hill Rd
Property Address
Owner Owner's Name -
information is Centerville Ma 4/12/14
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
40+
Estimated depth to high ground water: 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:
usgs topo maps on line
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Hi Ona Hill Rd
Property Address
Owner Owner's Name
information is required for every Centerville Ma 4/12/14
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
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w, VlFon& 1j3ftlUdWLV0AU.n_ :) =_Qdr g3ft Return Receipt 102595 02-M-1540+
Town of Barnstable
Regulatory Services Department
* IIARNS"CABLE• `
"A3
�67q. Public Health Division
DO ��
ArE p MAC a 200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Certified mail 70062150000210417675
August 15, 2008
1 AJ 5r1C L--r 4G10
James Bowes G
lqla
146 River View Lane �2 b
Centerville, MA 02632
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II- MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION,
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 18 Hi-on a Hill Road, Centerville, was inspected
on August 12, 2008 by Jaime Cabot, Health Inspector for the Town of Barnstable. This
inspection was conducted on the basis of a rental registration in accordance with Chapter
170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.482: Smoke Detectors and Carbon Monoxide Alarms:
No smoke detector was present in the upstairs bedroom and the basement smoke etector
was missing a battery.
105 CMR 410.500: Owner's responsibility to maintain Structural Elements:
Door handle.to Bedroom door is broken and knob falls off.
105 CMR 410.501 (B): Weather tight Elements: Standing water in basement possibly
due to rain water entering the dwelling.
You are directed to correct the violations listed above within twenty-four(24) hours
of your receipt of this notice by installing smoke detectors in accordance with Mass
Fire Codes and by replacing the broken door handle mechanism in the bedroom.
You are directed to correct all of the other violations listed above within thirty(30)
days of your receipt of this notice by correcting the problem of water entering the
basement.
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 may result in a fine of$100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
cc: Health Inspector
Certified Mail#7006 0810 0000 3525 3060
� T Town of Barnstable
x Regulatory Services
t )MA RtvsrA1tF,
�. wnss. g Thomas F. Geiler,Director
OD x639.. ,
°rF n+►r �' Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
September 21, 2007
James Bowes
146 River View Lane
Centerville, MA 02632
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II —MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 18 Hi-Ona-Hill,was inspected
on September 21, 2007 by Timothy O'Connell, Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of the rental registration in
accordance with Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements.
Observed walls in back bedroom that had cardboard and sheets on them. This appeared
to be in place due to the fact that this room is not weather tight and is not in good repair
as the above code states. The sheets and cardboard were damp to the touch and not free
from chronic dampness.
105 CMR 410.351 —Owner's Installation and Maintenance Responsibilities.
Observed many missing face plates on light switches and plug receptacles.
105 CMR 410.256—Temporary Wiring.
Observed extension cord being used as temporary wiring for clothes washer and dryer.
105 CMR 410.482—Smoke Detectors.
Observed that smoke detector within home not working.
QAOrder letters\Housing violations\Rental ordinance\118 hi-ona-hill.doc
105 CMR 410. 401-Ceiling Height. Observed that the ceiling height in most of the
rooms throughout home were 6'6"
The following violations of the Town of Barnstable Code were observed:
170-10—Maintenance of Smoke detectors and Carbon Monoxide Alarms.
Observed that home lacked a carbon monoxide detector.
170-7—Posting. Observed that the proper posting of owner's information was not
properly posted within home.
5� 9-3 (a)—Prohibition. Observed three beds in back bedroom when only two are
allowed within a 100 square foot bedroom
You are directed to correct the violations listed above within thirty (30) days
of your receipt of this notice by pulling any required building permits (if
applicable); by making back bedroom weather tight which will alleviate chronic
dampness; by installing face plates on electrical switches and electrical receptacles;
by removing temporary wiring connecting washer and dryer to electrical services;
by installing both smoke detector and carbon monoxide detector; by posting owners
information within home; by removing one of the beds in back bed room; by
correcting ceiling height from 6'6"to proper height of 7.0'
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
Q:\Order letters\Housing violations\Rental ordinance\118 hi-ona-hill.doc
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FORM30 CIW HOBBsB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE TH
CITY/TOWN
DEPARTMENT
ADDRESS 6�
GSM S 0y`or
o I (-A TELEPHONE
Address �1 4� � � I Occupant s�
Floor Apartment No. No.of Occupants Am
No. of Habitable Rooms No.Sleeping Rooms_
No. dwelling or rooming units_ No.Stories
Name and address of owner �1
1LI 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:
Stairs: V
y
lighting: "^
STRUCTURE INT. Hall,Stairway: 0 (
Obst'n.:
Hall, Floor,Wall,Ceiling: r' Icy Lf /
Hall Lighting: A,,,, +/
Hall Windows: arv%
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 Vents ✓ /
ELECTRICAL Panels, Meters,Cir.: !�✓' r� �//
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box: /
Gen. Basement Wiring:
.� �l,) a5 i/
DWELLINO UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1 J rC p
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
S,I,Wks, F ues,Vents feties:
Kitchen Facilities Si k�)
UO-
ove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR. (See Over)
"THIS INSPECTION REPORT IS,SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY."
INSPECTOR TITLE
DATE I - a i - O J
� TIME P•
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.
t
FORM30 Cs1 • HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
CITY/TOWN
W 1 {
DEPARTMENT
ADDRESS- ""J
°-t,y SyOy`oW
p {� I TELEPHONE
Address ' 0 �" i Occupant_ '-`
Floor Apartment No. No. of Occupants ��"""'�
No.of Habitable Rooms—No.Sleeping Rooms
No.dwelling or rooming units No.Stories_
Name and address of owner1'_ - _ '
Ia 6 Kam✓ V' 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: n
Stairs: r
ti htin :
STRUCTURE INT. Hall,Stairway: ` .. .b n d
Obst'n.: r v
` Hall, Floor,Wall,Ceiling: `�IU 0
Hall Lighting: — ,�.; '�cv� 254,AtUyw-r_ Lho � ✓
Hall Windows:
HEATING Chimneys: _ xv G%1aft,►+�.
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.: 4- fz"e �y
AMP: Gen.Cond. Distrib. Box: /
Gen. Basement Wiring: r� LI(U 9 5(0 t/
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1 • 110 r( 3 { :5 6
Bedroom 2 o E
Bedroom 3 !
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
S, cks, Flues,Vents,,,Safeties:
Kitchen Facilities Sirik 0 G`
�Tove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin, Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n: A _
General Building Posted A le&Z /
Locks on Doors: v .,
ONE OR MORE OF THE,VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
C 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 OFt�P,,E��RJJ�URY."
INSPECTOR �G�w^.I- �. �rC'" TITLE -
V Q
a - o
.,DATE � _ � TIME P.
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
BOARD OF HEALTH
� b
ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION
Date A"01-7
Owner ,/� Tenant
Address lam/i --C A),Q /1//�� C fV 1Adress
Complionce Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities
3. Bathroom Facilities 6/
4. Water Supply
Q -lie/*jv,-
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities 1
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17. Temporary Housing
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Person(s) Interviewed Inspecto
If Public Building such as Store or Hotel/Motel specify here __._
Certified Mail#7003 1680 0004 5458 5354
-ow Tati Town of Barnstable
` Regulatory Services
,
• BARNSTABLE,
9� A g Thomas F. Geiler, Director
ArEbMAIA Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
August 24, 2007
James Bowes
146 River View Lane
Centerville, MA 02632
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. �Q
The following violations of the Town of Barnstable Code are:
l� 70-4—Certificate of Registration. Rental property is not registered with town health
t 1
division. n \
You are directed to correct the violations listed above within ten (10) days
of your receipt of this notice by registering the rental property with the Town
Health Division.
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.
RDER OF BOARD OF HEALTH
o PsA. cKean, R.S., CHO
Director of Public Health
Town of Barnstable
QAOrder letters\Housing violations\Rental ordinance\18 Hi-Ona Hill Road.doc
SENDER: • •N COMPLETE THIS SECTIONON
■ Complete items 1,2,and 1 Also complete A. Si nature
item 4 if Restricted Delivery is desired., O Agent
■ Print your name and address on the reverse X � ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C. at of livery
■ Attach this card to the back of the mailpiece, Q
I or on the front if space permits.
D. Is delivery address different from Rem 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: 0 No
urn.QS ��.a�S
INb
3. Service Type
C �� L u•���t �A pZV'�Z *Certified Mail O Express Mail
0 Registered R Return Receipt for Merchandise
❑Insured Mail 0 C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. ArtMWWW rrcm Number
la>�' ; 117 0 0 8 16'8 0"10'0'0'4 i`5 415 8�`S 0 838°
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-15400
I
I a .
UNITED STATE PO. Tq�;�a[I�E;
#:...., f,4A 02-3 aid
• Sender:Please print.your name, address;and-ZI +4 in this box.•
I
I
I
Town of Barnstable
I (( ) Health Division
200 Main Street
I Hyannis,MA 02601
I
I
I
I
1
s i
IKE Town of Barnstable
Regulatory Services Department
• BARNWABLE,
MASS.
1639. Public Health Division
Arf°MA+a 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
July 30, 2007
}
e
James Bowes
146 River View Lane
Centerville, MA 02632
RE: Rental Ordinance - Chapter 170 of the Town of Barnstable Code.
Dear James:
I am writing in regards to the new rental ordinance for the Town of Barnstable.
Please be aware that we did not receive the fee to register the rental property owned by
you located at 18 Hi-Ona Hill Road, Centerville. Also, no phone number was provided
to contact the tenant to schedule an inspection as part of this rental ordinance. Please
send payment in the amount of$90 made out to the Town of Barnstable and furnish the
tenant's name and phone number so that we can contact them to schedule this inspection.
Please send to:
Town of Barnstable
Health Department
200 Main Street
Hyannis, MA 0260
Failure to comply will result in fines. Thank you in advance for your cooperation
and attention to this matter.
Respectfully,
Caitie Barrett
Rental Program Coordinator/Health Department
Direct Line # 508-862-4072
CERTIFIED MAIL#7003 1680 0004 5458 5088
;=c
Town of Barnstable
Regulatory Services
�oFT"E TOyti Thomas F. Geiler,Director
Public Health Division
* BARNb-!'ABLE,
v� b `�,� Thomas McKean,Director
�o- 39. A 200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
July 3, 2007
James Bowes
146 River View Lane
Centerville, MA 02632
RE: 2007 Rental Registration Fees
Dear James,
I am writing in regards to the new rental ordinance. Please be aware that we did
not receive the fee to register this rental property. Also, no phone number was provided
to contact the tenant to schedule an inspection as part of this new rental ordinance.
Please send payment in the amount of$90 made out to the Town of Barnstable and
furnish the tenant's phone number so we can contact them to schedule an inspection.
Please send to:
Town of Barnstable
Health Department
200 Main Street
Hyannis, MA 02601
Please reference the address of the rental unit on the check(or on a note enclosed
in the mailing). Once the payment has been received, I will input the information into
our registration database, and contact the tenant to schedule an inspection.
Respectfully,
Caitie Barrett
Health Division
Rental Program Coordinator
#508-862-4072
COMPLETEI SENDER: •N COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Sig ature
Item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that this
can return the card to you. 13a f y(Printed Name) C. mat of Deljve�
■ Attach this card to the back of the mailpiece, � v
er on the front if space permits.
D. Is delivery address different from Item 1 T ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
3. Service Type
EB Certified Mail ❑Express Mail
❑Registered ®Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?Pft Fee) ❑Yes
2. Article Number ;7pp3 04.;5458 5354.
(rmnsfer from service label) �0
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
i
UNITED STATES PQSTAI,,SI �/IC �, FFrSY-"C11�5s[Vfail
• Sender. Please print your name, address, and ZIP+4 iinr this(box •.A�
I
Town o:Barnstable
Health Division \,
200 Main Street
_ Hyannis,MA 02601
I
I
� 3II'.PP??If�i�f?FIiF?PiF3l�Pi?PIIt:iPIIPF!!?i!1�3?P?I�fP!f1PIP�
._ ..._ _. .. _
A
Commonwealth of Massachusetts co
f"
Title 5 Official Inspection Form4
(�
Not for Voluntary Assessments G" 01
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important: S 0-7
When filling out 1. Property Information:
forms on the computer,use 18 Hi-Ona Hill Road-Centerville, MA
only the tab key Property Address
to move your Robert and Judith Nolan
cursor-do not Owner's Name
use the return
key. 40 Oak Street
Owner's Address
West Barnstable MA 02668
City/Town State Zip Code
Bra Date of Inspection: June, 20, 2005
Date
2. Inspector:
David D. Coughanowr, R.S.
Name of Inspector
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364 0894
Telephone Number
Certification Statement:
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
�,�..�(, o6. G� K S June, 20, 2005
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.
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
A
Z
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
y` Subsurface Sewage Disposal System Form
A. Certification (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> A septic 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 ❑forthe 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:
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Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
B) System Conditionally Passes(cont.):
❑ 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
❑ 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
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
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.
❑ 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 and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached
to this form.
3. Other:
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Page 4 of 16
.1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
A. Certification (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
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 %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure criteria are triggered.A copy of
the analysis must be attached to this form.]
Yes No
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
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.
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
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, including 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(3)(b)]
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
C. System Information
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
Number of current residents: 3
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 162 gpd
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: May, 2005
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):
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Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: owner
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
❑ 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: 10+years. Certificate of compliance issued 6130194(Board of Health permit#94-321)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
2
Depth below grade: feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
20+
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):
1
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon)
6inches
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 28 inches
1 inch
Scum thickness
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 14 inches
How were dimensions determined? Probe to top of tank
t5-2087.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
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 not required at this time but maintenance pumping is recommended within and 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):
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
C. System Information (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
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.):
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert At outlet inverts
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. Few solids in sump.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
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:
❑ 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. An observation hole was dug into
leaching gallery stone and no effluent contact staining or standing effluent was observed.
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
CitylTown State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
16 Hi-Ona Hill Road
Property Address
Centerville MA 02632
CityTrown State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
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 g
1 10 ft 31 ft
2 15 ft 22 ft
A
SEPTIC EXISTING <
TANK o DWELLING O
CK
2
D-BOX # 14
B U <
LEACHING Z
GALLERY O
z I
J
K
111
3
I
NOT TO SCALE
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
. . � Commonwealth of Massachuset
ts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
18 Hi-Ona Hill Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Robert and Judith Nolan June, 20, 2005
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water: 25+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:
Barnstable 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 over 20 feet above
groundwater table.
t5-2087.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
;.. QN4l��LL �
TOWN OF BARNSTABLE
LOC A- N =:-)-0 7 /VW>A.I s7- SE W A G E # 9Y—
VILLAGE Cl!: F- ASSESSOR'S MAP & LOT,` Q-9--ON
INSTALLER'S NAME & PHONE NO. � �� ��+•' � -?�e
SEPTIC TANK CAPACITY /OGU
LEACHING FACILITY:(type) /nb�,c r- s CIL, (size)
NO. OF BEDROOMS PRIVATE WELL OR BLIC WATE
BUILDER O OWN ` QtilfCS, cTQ'i�'1aS
DATE PERMIT ISSUED: '
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes
a07
�y
No.,! J�.�... Fss....... ...................
D THE COMMONWEALTH OF MASSACHUSETTS
AM
ft"wmroI=w,4*M , ► RD OF HEALTH
T� N OF BARNSTABLE L-
, ;�.,
s, lirttti>an �> t li ngtt1;ork,i Tomitrnrtinn rnmit
Application is hereby made for a Pe it t Construct ( ) or Repair K an Individual Sewage Disposal
System at: IS f4 i � 1�1 ►
p207 GCAYt CJIJ Cl t LA-f
...................................... .. ................ .................................... ••••--•-•----•-----••••-••-------•-•---••.....--•'--••---•----••-•---•............•••.............
Loca address, o Lo �°%
....... •••. ..................... ....•.. ... �J t I[�(.�
Owne _ ' v� �J ddress p
t
Installer Address
UType of Building Size Lot.................... Sq. feet
�-, Dwelling— No. of Bedrooms___________________ ---------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons.-_-_-__---________-------- Showers ( ) — Cafeteria ( )
a' Other fixtures -
W Design Flow................ -------------gallons per person per day. Total daily flow---------- ....................gallons.
WSeptic Tank—Liquid capacity -_gallons -length________________ Width................ Diameter................ Depth................
x Disposal Trench—No. ......./......... Width......7_--------- Total Length.__'." _ Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter-------------------- Depth below inlet------/........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.........................----••••••--•-•------•-•---••----•--•-•-•--•---- Date........................................
Test Pit No. I................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 ••--•---•--------------------------•---••••------••----•••-•----••-•-----••-•-••----••-•---............................................
0 Description of Soil..............................................................................................................................................................................................
W
U -----------------------------------•-------•---••---------------------------------------•----------•-•-----------------------------------------•---------------------------......--•----•-•------•-----
W
x -•---•-------------------------------------•--•--------•---------------------------•-----•-••------•-----•---------------------------- --------------------j--------------------••--------•--
U Nature of Repairs r Alterations—Answer when applicable....C 'f.��- "----�UU� t-T19 'PL
-----------------••------------•------
4 S,' 1 G x r- -----%/4/ `,.f / i- pia►•:'ir
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complianc s een iss b 1pe board of health.
Signed ........ - ~...- � 1 ......
Application Approved B ............ _......'
........................... ............................................... ................Dace
Application Disapproved for the following reasons: ....................................... ..--.................. ...............................--......... .............
------------------ --- ---..--..------------------------..-------------------------------------.------------- ---------------..--------- -----.-.-.------------------------------..------ ------------- ------------------
te
Permit No. --- ---r -'J-- ------------------- Issued -------e`":/..`-�`' -
Date
.v ————————
-------- ----------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J�{TOWN OF BARNSTABLE
Appliration for Diij-pw3al Works Tomitrurtinn Vantit
Application is hereby made for a PejTit t9 Construct ( ) or Repair (!� an Individual Sewage Disposal
System at: g 1 �tr1 1� 1 I
C71)07 ` �� S i 6'C"(LA U i, L 4.
..................................................... -•---------------------•--•-•-------•-----•--------- -•----....•----•••--•---•......------------
Loca"lion.•Address or Lot N
------..... ••--•----•------••-•---------•--•-• •• ......-•-----•.........._
Owner ddross
M
( % .4YI t t t
•--•--•-•-----------------•-----•--.r......--- •----------•----•••-•--------•-•-•-•--•-
Installer Address
Type g Size Lot.................•.. Sq. feet
U T e of Building --•-_-
.—I Dwelling— No. of Bedrooms----------------�-?-------__---__-..----Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures-----------------•--•-•-•-•-------•--•......•------------••-----------.....-----........................-----•---•--............-••--..........-•--
W Design Flow................. .5 ------------gallons per person per day. Total daily flow----------:-� ....................gallons.
WSeptic Tank—Liquid capacitv, ��4?_-gallons Length-_-_---_---__ Width-._-_-------_- Diameter................ Depth................
x Disposal Trench—No. ......./----------- Width___-_--7-........... Total Length.__-009'.�..... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter-------------------- Depth below inlet------l............ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1.4 Percolation Test Results Performed by-------- -----•-------••------•--••••--••-----•--•---•--•----•-•-••-••---- Date........................................
,.�. Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.___-.-.--____---_-----
Gi Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
Gd •--••--------------•-•--•-•--•-•--••---•--------....---............_............•--•----•---------•.........................................................
ODescription of Soil........................................................................................................................................................................
x
IJ ...................................... ••-------•---•••-----------•-•--••--•---•--•-•••--•-•-.......-••-•--•---•••••••-••-•-••-•••---------••••--••------••-----•••----------------••..........---.......
x •------••---••--------------•------••---------•-•-••---•-•-•------------•••••--•-------•••---••-•••-----•------------•-------...-----•......---------•-------••••.
U Nature of Repairs r Alterations—Answer when applicable.... s% '�L_�______�l�U 0� ................................S�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliances s been isst�' by the board of health.
/ .�... .Signed --- I.. -` ----`--- -----------`-------------------------------------- �! . �`5_. ..
.�� .. 1�
Application Approved B ....... .. ..... "t�..,7
-
LYate
Application Disapproved for the following reasons- --- --------- ------ ----------------r-------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------1---------...----------- ........................
Permit No. - F1.—... ..........:........ Issued ........l ..".�-,� .
r ce
Dare
— -- ———: —-----
—---
. _. -- —— �--.------
.—---
.-- ———..--—— ————--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifirate of Compliance
THIS IS TO CERTIFY, That_the Individual Sewage Disposal System constructe ( ) or Repaired
by ....- - ..... l-GT7----------------�3'iJJTr-L�C...iG.__.... ......... . . .. -- ........
Insrdler
a ---------------------------------------------------------------- -----
has been installed in accordance with the provisions of TITLEj of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..... ....r--.��1 ...._ dated .-"t' � r-..�'c�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
k
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............................� ----------------------------- Inspector -----...... .` .......... ..~1---.-----------------__--------------------
-- ------------------------------------------------------------------ ----
THE COMMONWEALTH OF MASSACHUSETTS _ G
BOARD OF HEALTH
�j TOWN OF BARNSTABLE -7 —
No � FEE....
Dispnttl Workii Tnn#rnrtinn rami#
tJ�—7 ....
Permission is hereby granted---------------------- - -----------------------------------------._...._..---------..........._............................
to Construct ( ) or Repair (k) an Individual Sewage Disposal _S stern
G'1'lr �i Ll �S J �C fir( a t '
atNo................................................... �,� ------ -------------------------------------------- --------- --- ---�� .....
stre t
as shown on the application for Disposal Works Construction Permit �Dated..... -- .....��
Board of Health
DATE............. ------.._.
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS '�