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HomeMy WebLinkAbout0078 WATERSIDE DRIVE - Health (2) 211 PINE STREET, CENTERVILLE A— //n✓2 z No. 42101/3 ORA ESSELTE 10% ® A O O Commonwealth of Massachusetts - Title 5 facial f 'O Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M6.1211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. important:When filling out forms A. General Information on the computer, S---� use only the tab 1. Inspector: � �� ,�, -� key to move your c� 0 cursor-do not David B. Mason ': Z use the return - key. Name of Inspector --- David B. Mason r� Company Name 4 Glacier Path ' -v Company Address East Sandwich MA 02537 :r City[Town State Zip Code C:) r�+ 508-367-1617 S1287 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 16.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority - v• June 30, 2014 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 211 Pine Street ' Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. 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 exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is Centerville MA 02632 June 27, 2014 required for every _ page. City/Town 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 a nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or."No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is Centerville MA 02632 June 27 2014 required for every , page. City/Town 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 ❑ ❑ 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 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Pine Street 'M Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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? i ❑ ® 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): 6 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 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 ears usage d Yes 9 ( Y 9 (gP ))� Detail 2012; 251,000 gallons and 2013; 189,000 allons Sump pump? ❑ Yes ® No Last date of occupancy: Current 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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: Board of Health 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: August 2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 12" 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: 2000 gallon typical Sludge depth: 3„ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 43" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PVC tees in place. Effluent level with outlet tee invert. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Pine Street M Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is Centerville MA 02632 June 27 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level with outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No indication of solids carryover. riser within 6 inches of grade. Effluent level with outlet invert 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: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is Centerville MA 02632 June 27 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5-500 gal units ❑ 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.): No indication of hydraulic failure. No pondin . Units dry. 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 Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. Citylrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Z. Surface water ® Check.cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design Ian reviewed: g p Date ® Observed site (abutting property/observation hole within 150 feet of SAS) z Checked with local Board of Health -explain: Ground Water Contour Map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database explain: You must describe how you established the high ground water elevation: Town groundwater contour map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 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 �M 211 Pine Street Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 Assessing As-Built Cards Page 1 of 2 A TOWN OF BARNSTABLE LOCATION a-/ X7. SEWAGE# VILLAGE -C tI _ASSESSOR'S MAP&PARCEL A INSTALLER'S NAME&PHONE NO. _tTi�l L��o 60�c' 7 roJo y SEPTIC TANK CAPACITY ao 0 o Ca'.Clt o w LEACHING FACILITY:(type)TLZErc.-e Fe njijw(size) /3 N S/'Jr�� NO.OF BEDROOMS_ 6 OWNER /l��.00A L eriyA' PERMIT DATE: —'3—/ COMPLIANCE DATE: J'— Separation Distance Between the: -y o jeol. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /Z 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 CT�/a1 LC�06y/`� 60 b-66 6 �- s.r•6 O ra-P or http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=248004001&seq=1 7/3/2014 TOWN OF BARNSTABLE LOCATION oZo� ��^'� J'T SEWAGE# VILLAGE �'°`�T�yr�� ASSESSOR'S MAP&PARCEL oP- INSTALLER'S NAME&PHONE NO. 0/-'! SEPTIC TANK CAPACITY ova o o ����a�✓ LEACHING FACILITY. (type) TQ �evotero`(size) /3 NO. OF BEDROOMS (� OWNER PERMIT DATE: C — --T ��® COMPLIANCE DATE: — �® Separation Distance Between the: Va.-® Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /- Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ,00000,,:::� - 7l o No. w—335 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:AZ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppItration for TBt9;pOga1 6p5tem Cow5tructtun 30Crmtt Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) ❑ Complete System U Individual Components Location Address or Lot NoaPO","" d0r/'OoeJ/1 Ci eAT Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: / Dwelling No.of Bedrooms O Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building a0p4o`­S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 4!��417 gpd Design flow provided 6/;< +� gpd Plan Date /® Number of sheets l Revision Date Title Size of Septic Tank Type of S.A.S.�Z�yye/� /��Q G1?/V�.& Description of Soil _ 6o �'ek i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board f Health. Signed Date c p —T--w Application Approved by Date Application Disapproved by: de Date for the following reasons Permit No. 2 0 j® 3,35— Date Issued �'��� �No. Ulf -33S < < � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION- TOWN OF,BARN STABLE, MASSACHUSETTS Yes 0(pplication'for MiOoMfl *p5tem CCon5trUction Per-it Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) ❑Complete System Individual Components Location Address or Lot No.oZ// 4�/.mac+' .�,� G Ct�T Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. %f�� Type of Building: / Dwelling a r No. of Bedrooms O 'Lot Size sq. ft. Garbage Grinder ( ) Other , = Type of Building 4e7E-r. 4 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �O gpd, Design flow provided 15 �l' d 1 gP Plan Date -7� �•%' Number of sheets .l Revision Date Title Size of Septic Tank -1��G�✓° /.1���q oZ Cow' Type of S.A:S. '�',AvG� Description of Soil _ ��-����• ��f wrsy/� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: F. Agreement- 'v The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage.disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board 9f Health. I'"•= Signed Date =PyS�®� Application Approved b PP PP Y 12SDate Application Disapproved by: `' Date for the following reasons s ' a .Permit No. 2 I d - Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance f' THIS IS TO CERTIFY,that the On site Sewage Disposal Syste rii�'�Constructed ( / ) Repaired ( ) Upgraded ( ) Abandoned( )by o`Z// / i/✓ a at �,�= has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '>U/0 —3�� dated — �U Installer�� L�.�O U/Z tip., Designer 49'3' 11y10:0 i #bedrooms d Approved de n fIAv d76_tCi`r gpd The issuance of this? chill not be construed as a guarantee that the system w'll c ion as de igned. Date Inspector q � v No. .Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS x1h9poml 6paem CCowarUction Ver.Mit Permission is herebyranted to Construct Repair Upgrade Abandon g ( ) p ( ) Pg ( ) ( ) System located at cz ✓� 4 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date J Approved by � + Town of Barnstable Regulatory SerAces _ Thomas F.Geiler,Director -- Public Health Division ' ! a Thomas McKean Director 200 Main Street,Hyannis,MA 02601 Office:-508-862-4644. -,Fax: 508-790-6304 Installer &Designer Certification Form Date: Designer. �( gn - � Installer: _) 1 Address: , Address: I On (S? was issued a perm-it to install a (date) (Installer) septic system at G&MO based on a design drawn by (address) dated (designer) I certify that-the septic system referenced above was installed sub stanhT.11 according'to design, which may include minor approved-changes such as lateral �locafi of the cfi.�tidbution box and/or septic tank. _ I certify That the septic system_T+eferenced above was installed with'�€a3du cran es greater th`M I" lateral relocafi6 of the SAS or-any vertical'mlb ti 'on of any compost of the.septiC system)but in accordance with State&Local Ile gzilahons Plan revisioxr o� certified as-bi t`by desi�aer t6 follow. _ - (Installer's Si e) •' :� ` : � .cn S .' .y . 9 � E - FOls (D er s Signature) (fix er'' Stamp here) PI ASE RETURN TO j6A�tI�S�' '3'U161�.I -�ALTII.DIVISID �C TE ��'- CONdF A1�CE Wf I .''N it`= UET3 BOTH-3' LS FE f DUMT A ARC R.ECF ED '.A.: B STA1 I.7E P LI DIi JiSg€?i11:' s. a _ Q:Healtb/.Seioc/Designer Certifi,Ag'Form TRANS. NO.: CITY/TOWN: APPLICANT: ADDRESS: L-L� DESIGN FLOW: gpd REVIEWED BY: DATE: N/A OK NO GENERAL Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u)] Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"= 20' or fewer for components) [310 CMR 15.220(4)] Easements shown[310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)(f)] daily flow septic tank capacity(required and provided) soil absorption system(required and provided) whether system designed for garbage grindei North arrow 310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h) Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and(i)] Location and date of percolation tests (performed at proper _ elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] AddressZ 'I ��d� ��JC� Sheet 1 of 7 N/A OK NO Location of every water supply,public and private, [310 CMR 15.220(4)(k) within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of private water supplywells Location of all surface waters and wetlands located up to 100 ft. / beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] V Water lines and other subsurface utilities located [310 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR 15.220(4)(o)] Stamp of designer 310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate(two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR 15.0001 System components not> 36" deep (unless Local Upgrade Approval or LUA requested) [310 CMR 15.405(l(b)] Address y I I l �^t ICE �'J Sheet 2 of 7 N/A OK NO SEPTIC TANK Size OK? [310 CMR 15.223(1)] Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227(6)] 1/ Outlet tee with gas baffle or approved filter 310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees (no less than liquid depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] VVV Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(l) and 310 CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<1000gpd, two fors stems>1000 g d [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8) H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] Multi-Compartment Tanks Required when other than single-family dwelling or flow>1000 gpd [310 CMR 15.223(1)(b)] First compartment 200% daily flow; Second compartment 100% daily flow [310 CMR 15.224(2) and(3)] "U"pipe through or over baffle, outlet of each compartment w7`7 gas baffle or approved filter[310 CMR 15.224(4)] Address I ���4� Sheet 3 of 7 N/A OK NO BUILDING SEWER AND OTHER PIPING Located at least ten feet from any water line? [310 CMR 15.222(2)] 1/ Disposal piping at least 18" below water line(when water and sewer cross, see 310 CMR 15.211(1)[1]) Cleanouts required/provided? [310 CMR 15.222(8 Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c) Siphonproblem/(leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h) Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) DISTRIBUTION BOX Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sum 6" [310 CMR15.232(3)(e) Watertight cover if<2000gpd);waterproof manhole if>2000gpd / [310 CMR 15.232(3)(d)] V PUMP CHAMBERS Capacity(emergency storage above working=design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and(8)] Stable Compacted Base [310 CMR 15.221(2)] IBuoyancy calculations needed?Provided? [310 CMR 15.221(8)] Address 7i ��we Sheet 4 of 7 N/A OK NO SOIL ABSORPTION SYSTEMS (SAS) GENERAL Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] GALLERIES,PITS,CHAMBERS 310 CMR 15.253 Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR I .253(6)] Each structure with one inspection manhole (if>2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate 1' minimum- 4'maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(l)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)] TRENCHES 310 CMR 15.251 Width T minimum 3' maximum [310 CMR 15.251(1)(b)] 100 feet-maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] BED SAS (Maximum size of bed or field 5000 gpd) minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6' [310 CM RI5.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. 310 CMR 15.252(2)(g) Separation between beds 10'minimum. [310 CMR 15.252(2)(0] Bottom area used in calculations only [310 CMR 15.252(2)(i)] Address l I ���`(� ✓i Sheet 5 of 7 N/A OK NO DID THE PLAN INVOLVE Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative / systems under remedial approval [310 CMR 15.254(2) and I/A ^ / Remedial Use Approvals] If used in gravelless system - make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems< 2000 gpd) or quarterly (>2000gpd) good to note on plan [310 CMR 15.254(2)(d)] Construction in fill - Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer[310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] Gravelless System[UA Approval Letters] Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Alternative Septic System[I/A Approval Letters] Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all 7Z DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance Variances Are the variances listed on the plan ? [310 CMR 15.220 (4)( )] RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed - [Refer to 310 CMR 15.414] � I, c Address -4 2 jJ� I "�1 qf, Sheet 6 of 7 N/A OK NO Nitrogen Sensitive Areas Is the system in a Designated Nitrogen Sensitive Area(Zone 11 for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2) Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] Miscellaneous Pumping to septic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] Address Sheet 7 of 7 TOWN OF BARNSTABLE ` BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date �D_ I 1 2-- Time: In Out Owner 0 Tenant D ,�j Address s Address �� Compliance Remarks or Regulation# Yes 0 Ono Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities .Z.— ti7v�CJ!; - 6. Heating Facilities ,,,,,R -:1�_ 7. Lighting and Electrical Facilities 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 16 17. Temporary Housing 18. Driveway Width F? �✓ l0 150 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition ,r} Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here i Date 5 24 1 To Whom It May Concern: I, , vohmtarily grant permission to the Town (Occupants name) of Barnstable Board of Health (Agent or Health Inspector) to inspect my dwelling unit located at l S I ►a V-0k rf=j0 "eYV l t I e in accordance (House#, [Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters59 and 170) and the State Sanitary Code (105 CMR 410.000 on LAJ^, - . `� I hereby auth 1 � y onze and name ii (Date of inspection) CGS to be my tenant representative for the (Occupant representative) purpose of this inspection. t is an adult person ( ccupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) Occupants Signa ture \ Date cc ants Representative Signature \ Date QARental Ordinanc6inspection pennission 2.doc s TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date — Time: In Out Owner Tenant 7W'-Y� Address 7 Address i Compliance Remarks or Regulation # Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities Arsocnved: - 4. Water Supply ' -' ` 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities i 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 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms _ Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here i 1 a Date , 2 To Whom It May Concern: voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health(Agent or Health Inspector) to inspect my dwelling unit located atC,_Clot YVl 1 in accordance (House#,[Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on F1/1 aL-4_� I hereby authorize and name (Date of inspection) to be my tenant representative for the (Occupant representative) purpose of this inspection. is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s-) \ 5- //2- ccupan s \ ate Occu ants Representative Signature Q:\Rental Ord inancc\inspection pennission 2.doc �� t TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date — l Time: In O t Owner Tenant Address Address Compliance Remarks or Regulation # Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply AO 5. Hot Water Facilities 6. Heating Facilities ' + 7. Lighting and Electrical Facilities 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 18. Driveway Width �. .(4— - 7e l 19. Number of Tenants Observed PART 11 37. Placarding of Condemned Dwelling; .Removal of Occupants; Demolition Number of Bedrooms _ Number of Vehicles Allowed (max) Y Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here I Date 51249 f Z To Whom It May Concern: Z.A'1-/y , voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health(Agent or Health Inspector) to inspect my dwelling unit 12A11 _ located at 1�a �,�1)0* ry( N] in accordance (House#, [Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code 105 CMR 410.000 on( ) 'F,r''1 I hereby authorize and name (Date of inspection) D�l to be my tenant representative for the (Occupant representative) 726'�. purpose of this inspection. (n is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) 66 Occ i re \ Date Occullants Representative Signature \ Date QARental Ord ilia nc6inspection permission 2.doc �� TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE If: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out Owner Tenant 3t5 Address Addresses--cam 1 Compliance Remarks or Regulation # Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply approve& 01 .� 5. Hot Water Facilities ` 6. Heating Facilities 7. Lighting and Electrical Facilities 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 0 to 33,5 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms - Number of Vehicles Allowed (max) Number of Persons Allowed (max) �- Person(s) Interviewed Inspector I� If Public Building such as Store or Hotel/Motel specify here Date '5 2 To Whom It May Concern: 1, Ei /�Qj YV , voluntarily grant permission to the Town (Oc upants name) of Barnstable Board of Health(Agent or Health Inspector) to inspect my dwelling unit located at 21( Tric Sh -4 1 tom✓1 (� in accordance (House#, [Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on FKi T�� I 1 hereby authorize and name (Date of inspection) b�h L11G� to be my tenant representative for the (Occupant representative) purpose of this inspection_ �t n is an adult person (Occupant representative), designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) _ cupants Signature \ D to Occ pants Representative Signature \ Date Q:\Rental Ord inance\inspectioh pennission 2.doc TOWN OF BARNSTABLE BOARD OF HEALTH r ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date IP` � 1 Time: In Out Owner 1 Tenant 14t�— Address —I 3 w Address ?�- Compliance Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities ' 6. Heating Facilities 7. Lighting and Electrical Facilities 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 to 17. Temporary Housing 18. Driveway Width, 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) �---; Person(s) Interviewed Inspector l� If Public Building such as Store or Hotel/Motel specify here Hey Guys, it's that time again! $p. Health Inspection required for all rental units. Friday, June 1st 10:30a.m. I will need this attached form signed in advance. I will pick them, up on Thursday around 5:00 on my way home from work. Or call me for other arrangements. Please make sure that all bedroom and basement doors are unlocked! Please make sure your home is clean and make a special effort to clean all mold and mildew A from the bathrooms and ceilings. Make sure all smoke detectors have batteries and 6-o fi are working!! Call me if there is a problem. He also checks water temperature, # of beds, electrical outlets. It won't take long and I will be with him in each apartment. Thank you! F, `F s Robin 508-776-7752 . : maddalena@?comcast.net t i '�`1 j :a ^/W �_ � � f � � .. . ��, ��f , � � �. �i ��� � ���� �/� � � J��o �� �.�� c,• r ;� ' - � - �� � L � 4 Jt � r •• �� S. - 1 ' �� ^I I . �` \ i ` � r �. TOWN OF BARNSTABLE BOARD OF HEALTH f ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date to` � 1 Time: In Out l� Owner Tenant Address 3 Addresses.,-.-cam s J Compliance Remarks or Regulation# Yes 11X0 Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply �. 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 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 0 t 6 3 3-5 17. Temporary Housing 18. Driveway Width 1'd 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector l� If Public Building such as Store or Hotel/Motel specify here Date To Whom It May Concern: I,—� E�� G 1'tl� A , voluntarilY ant permission to the Town L (Occupants name) of Barnstable Board off Health(Agent or Health Inspector) to inspect my dwelling unit located at }'[ ,54, CJfr1t6'-0 i I k' in accordance (House#, [Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code 105 CMR 410.000 ( ) on �{� I . �� I I hereby authorize and name (Date of inspection) to be my tenant representative for the (Occupant representativ 1^ purpose of this inspection. C/t/'1 i P s an adult person (Occupant representative) i. designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) \ �- Occupants Signature \ Date Oc upants Representative Signature \ Date QARental Ord inanc6inspection pennission 2.doc i � z - TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date IP` Time: In O Owner Tenant Address Y Addresses-�-c� Compliance Remarks or Regulation # Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply _ y 5. Hot Water Facilities � Avv 6. Heating Facilities 7. Lighting and Electrical Facilities 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 ,V- 0 f 4 3 3,5 17. Temporary Housing 18. Driveway Width 17� ' 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector I� If Public Building such as Store or Hotel/Motel specify here I r Date NCO To Whom It May Concern: I, , voltmtarily grant permission to the Town Occupants name) of Barnstable Board of Health(Agent or Health Inspector) to inspect my dwelling unit located at 7P- 4in accordance (House#, [Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on Tkr I I hereby authorize and name (Date of inspection) to be my tenant representative for the (Occupant representative) purpose of this inspection. . an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) Occup. Si ture \ Date i Occ ants Representat ignature \ ate QARental Ordnance\inspection permission 2.doc I i Towne of Barnstable P# UU Department of.Regulatory Services Public Health Division DateKAS& ? �� 039. tee$ 200 Main Street,Hyannis MA 02601 r� J Date Scheduled / v Time v Fee Pd. / v i ,foil Suitability Asse sment for Sewage isposal Performed By: Witnessed By: LOCATION & GENERAL INFORMATION Location Address ( P! 1, Owner's Name M���a I e✓1% ���`t� Address Assessor's Map/Pdreel: ({�_ V�t�—(�' Engineer's Name NEW CONSTRU�,'1'ION REPIAIR Telephone# i Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet'Area ft Drinking Water Well ft Drainage Way ft. Property Line ft Other ft e dimensiods of 1 exact locations of test holes&perc tests,locate wetlands in proxitnity to holes) SKETCH:(street name, lot, i 1� o Otrt� Parent material(geologic) ! Depth t0 Bedrock I Depth to Groundwater. Standing Water in Hole: Weeping from Pit FAce Estimated Seasonal ilIigh Groundwater DtTERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: i Depth C1bperved standing in obs.hole: __In. Depth t0 soll MOtdgs: In. Depth tomeeping from side of obs.hole: in, ©roundwater Ad)uettnent ft• Index Well# Reading Date Index Well level —--_ Adj.fai tar--.�m Adj.�rpunAwnter Level i PERCOLATION TEST Dale Tl4ne Observation '� I I I Time at 9" Hole# ----�j— Depth of Perc ' Time at G" Start Pre-soak Ttrue.@ Time(9"-6") End Pre-soak L Rate MinJlnch Z�7� Site Suitability Asseissment Site Passed Site Failed: Additional Testing Needed(Y/N) Original:.Public Hehith Division Observation Hole Data To Be Completed on Back----------- ***If percolaAion test is to be conducted within 100'of wetland,you must first notify the Barnstable C40servation Division at least one(1)weidk prior to beginning- q\SEPTiC\PERC17 I11M.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel -- Ic 1p DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C nsi ten ra - -Flood Insurance Rate May: - - — — -— - Above 500 year flood boundary No_ Yes Within 500 year boundary No� �.- es Within 100 year flood boundary No�Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth f n urally occurring per,ous material? Certification I certify that on )Q (date)I have passed the soil evaluator examination approved by the Department of Envirotimental Protection and that the above analysis was performed by me consistent with the required training,a rti nd xp rience described in 310 CMR 15.017. Signatur Date r D Q:4SEP'rIC\PERCFORM.DOC No. 2 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for �Btgogal 6pgtem Congtructton Verna Application for a Permit to Construct( ) Repair x ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Locatio ddress or Lot No % I Owner's Name,Address, d Tel.No.�T 7 71—3�t}q Assessor's Map/Parcel I Ll a- Installer's Name, ddr ss and Tel No ���— a 7�` D si ner's Nam Address and Tel.`Nso.�� 1'?x)0 Iq a7 d rr► b �i Scrams S'.�'- i G v,r, i Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder (W Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank [ 5 W Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) S e-O�G SIBS (ram ® r ) — 7— 7—O Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ea / Signed Date Application Approved by v Date -7— Application Disapproved by: Date for the following reasons Permit No. d� Date Issued ".�''+Je`""'"`"f'*. '..'�sa+'�sr i,s'F`-..n1r�'rr:�,"'`y„'tiLti1-'�":r=,�s*di--"'...-'� _` �y%w j'7+r.•"'"':+g,,., ..lr: ,Y„�a..e�`t +' ."Y x.1 ..-�..•„r,..,,� �.-- s..,..�T _ Nor Fee �W THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 11-1 PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Yes N 9ppltcation for ai!6pogaf i§p!gtem Conotruction Permit Application for a Permit to Construct( ) Repair( •Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location, ddress or Lot No.. Owner's Name,Address,and Tel.No.� 0—'771—3�V L1 c9 �i n2�e-1 LiV�, � v' �"Pd -+n 5e h a.,bl I iK Assessor's Map/Parcel 010,8� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. rn f<0b► nsu- .Sr 9,0-f+iL U L-jay-\S. a �5c�c k oqol 0 4,c ry i 1 kz 2 tom, l-kA-(-rjy 2C(P 40,v)r,; Type of Building: r_.. Dwelling'' No.of Bedrooms Lot Size sq.ft. Garbage Grinder (AD Other Type of Building + No.of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow(min.required) gpd Design flow provided gpd —Plan Date Number of sheets Revision Date Title b, x r Size of Sepiic Tank 1500 4 Type of S AsST - e-�,q Description of Soil Nature of Repairs or Alterations(Answer when applicable) l 1 �S `Cf)��� 'n7 ► ►`, S - Ip�,v� o�C La,\sc., (�c.l��. -m-t g� 7— 7—O V Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to,place the system in operation until a Certificate of Compliance has been issued by this Board of Hea •. Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued ---------------------------------,------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the�On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) < Abandoned( )by W q,^ SUN' C,,Qy T r C- *` has been construe ed aceordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '"` dated Installer Designer , #bedrooms Approved design flow e e gpd The issuance of thit shall tt-be-construed as a guarantee that the system Wily l/unctiiionn afs`d/essigned, Date 71d,11,J�C/ Inspector ---No: 2b6(�- gTHE ------------------- Fee . �QQ COMMONWEALTH OF MASSACHUSETTS { PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS s 0i!gpoml *potem Con!5truction Permit Permission is hereby granted to Construct ( ) Repair (��)t Upgrade (� ) Abandon ( ) System located at Pi Yl��� ('Q.I? �(Z ( YQ, 1� .+fl` ('�/+ ,' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. ` Date ��' ��� Approved by r' x � l� I Town of Barnstable Regulatory Services Thomas F.Geiler,Director • aarixsrnBM a $ Public Health Division c6;9 1e Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 u4 Installer&Designer Certification Form Date: S b� Sewage Permit# &ff Assessor's Map�Parcel 23 � J � Designer: -yct4.5 Installer: -Ka b / rt,7,sJ6 yv Address: 2 W. �yts 1 S1�on -c c,� Address: )o 9d 7 L, uA On S ��5 '�' was issued a permit to install a (date) in 4- septic system at , based on a design drawn by (address) L> G dated (designer) - 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. P��N o F M4,9 AC s� LISA C. LYONS = ns (Installers Signature) - - ;LIC. #1143. •: ,jFG ••;Gl.iall •• �P��` ,A &ii�S ' esigner's(Si a e) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU Q:Health/Septic/Designer Certification Form 3-26-04.doc Town of Barnstable P# /6- Department of.Regulatory Services • Public Health Division Date �- d i639. e$ 200 Main Street,Hyannis MA 02601 �rED IAt►�� Date Scheduled (!� /® : Time Fee Pd. / v Soil Suitability Assessment for Se age Disposal Performed By: Witnessed By: LOCATION & GENERAL INFORMATION Location Address 2i �I�I>; -f•avet Owner's Name t� �i�✓I�,�j Address erne, Assessor's Map/P4rcel: Engineer's Name 1 SGZ- Dom'!S NEW CONSTRU�`TION REPAIR Tel ephone# Land Use Slopes('3o) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well _--it Drainage Way :ft. Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity toholes) a _ � t ily� T2� O • l^J � 7� t_ Parent material(geglogic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: 1 O Weeping from Pit Face Estimated Seasonal Nigh Groundwater DUTERM.WATION FOR SEASONAL HIGH WATER TABLE Method Used: g, in. De th to sail met OM �, Depth C1b�erved standin in obs.hole: p Depth toiwee in from side of obs.hole: in. ©roundwater Adjustment f� g.05 Index Well# IWP Reading Date 5.1$ Index Well level Adj.faetor-., a_ Adj.Orwoundwater Level PERCOLATIOIN TESL' Date- Vie• Observation I Time at 4" -- —. Hole# 42_<-9+4 79me at 6"Depth of of Perc Start Pre-soak Time.® 1 D-,$ 'rime(9"-6") End Pre-soak Rate Min./Inch Gyt y�i/t Site Suitability Assessment: Site Passed `' Site Failed:. Additional Testing Needed(Y/N) Original: Public He*lth Division Observation Hole Data To Be Completed on Back-------- ***If percola#on test is to be conducted within 100'of wetland,you must first notify the Barnstable C40servation Division at least one(I)week prior to beginning. Q:ISEPTICIPERCF�RM.DOC DEEP OBSERVATION HOLE LOG Hole# I Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Struc re,Stones,Boulders. Consistenc % ravel 14 1.S mw-4/3 i DEEP OBSERVATION HOLE LOG. Hole# `2— Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. 'Consistenc %Gravel) 144 G M GS 2•�") PEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel It 11 t�� IL WIRI 'DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structutc,Stones,Boulders.t� onsistenc myel 1L . i Flood Insurance Rate Man: Above 5,00 year flood boundary No— Yes Within 500 year boundary No � Yes Within 100 year flood boundary No -� Yes Depth of Natutally Occurring Pervious Material Does at least foOr feet of naturally occurring pervious Material exist in all areas observed throughout the area proposed fbr the soil absorption system? ____/ If not,what is the depth of naturally occurring pervious material? Certification I certify that on. P (date)I have passed the soil evaluator examination a b the � �� approved Y Department of trivironmental Protection and that the above analysis was performed by tree consistent with the required training,exnertise and a hence described in 310 CUR 15.017. �...` (DLi11083 Signature Date Q:\.SEPTICIPERCFORM.DOC � ` FORM30 H&W HOBBS&WARREN'M THE COMMONWEALTH OF MASSACHUSETTS �� BOARD OF H LTH CITY/T WN 4 W DEPARTMENT 'o ADDRESS GSM Syeyw JTEIHO"E P Address 2-VI Occupant__ — p Floor Apartment No.of Occupants No:. of Habitable Rooms_No.Sleeping Rooms— No.dwelling or rooming units_ No.Stori Name and address of owner N Remarks Reg. Vio. YARD Out B d 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: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: . Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: . AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 y5U Bedroom 3 b Bedroom 4 7 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REP RT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJ INSPECTOR TITLE _ Ia� AM DATE ✓� TIME V 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. - - i a FORM 30 &w� Hoees&WARRENrm THE COMMONWEALTH OF MASSACHUSETTS s,u _4� CITY/ OWN W1 V a D P RTMENT a ADDRE / f 1 LEPHO�(EE Address,9// PJ/ �®� (& KV /�OccupantjJ;�e Floor Apartment No.p: No.of Occupan s � No.of Habitable Rooms� _No.Sleeping Rooms No.dwelling or rooming units No.St ri s Name and address of owner, ' 'L - 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: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks,Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: 11110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom —Pantry Den —Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: General Buiidin 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 IN C ION T IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI R RY.' INSPECTOR. TITLE A.M DATE `� TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. -. :.. ,�...,,,. _...., r_ L: rY;. s k`?.^'�a;...;.-r'�-,s w ,..or,�-k'��.'ak:i•.L.......r�.� .:-c4-:..•-w.c...�.._..�.. ... w.�..:+�....1,__r..,,,_..,,,.r;,.,, ,.. ,,,, ..-.-..` :.v,,,,,,r,.e„r„�.,.,.._.- .... ! I 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 ordertis 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-raiIing 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. III (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. - f 1 ' . ' ORM30 C&W HOBBSBWARRENrm THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H LTH CITY/TOWN q DEPARTMENT ADDRESS �M Sey`0 S L TELEPHONE Address I � -' 1— _ Occupant_ Floor Apartment No._ No.of Occupantsf No.of Habitable Rooms_ No.Sleeping Rooms No. dwelling or rooming units No.St ri 01 Name and address of owner—_ �- — 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: Ah Chimney: 4. BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.:0110 ❑ 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 . p Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJUR " ram_ INSPECTOR TITLE DATE ppb "- TIME ©' K(S 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 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, x ose the occupant or anyone else to fire burns shock accident or other danger or impairment to health or safety. so astoe p p y g p y (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. �. � Date '�' <c;/)' To Whom It May Concern: voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health (Agent or Health Inspector) to inspect my dwelling unit located at a T 1 N �T. 812t 2 (W. ��7 in accordance (House#, [Apt\Unit#if applicable],street,village) es with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on Let/05/ ID:OCR I hereby authorize and name ((15ate of inspection) O ►1 V i 1C,� _ c4 PhC� to be my tenant representative for the (Occupant representativel purpose of this inspection. is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) lllf / cupants Signature \ ate \ to Z./c Occupants Representative Signature \ Date Q:\Rental Ordinance\inspection permission 2.doc � ��s�� 1 G� �/ y FORM30 C&W HOBBSBWARREN'" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ALTH P Y/TOWN W iv ENT DEPART ,� Mf 69 L) 'o ADDRESS °�M 5 By`0W j� TELEPH NE /� n Address rQ 1 1 r" ikx 5�-, �� Occupa Floor Apartment No. 1,3 No.of Occupants —�- No. of Habitable Rooms_,No.Sleeping Rooms—L_ No. dwelling or rooming units_ No.StQri j Name and address of owner `` I eok*ry l/e Remarks �1.9- Vio. /� - YARD Out Bld s.: Fences: `s o Garbage and Rubbish Containers: n 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: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect..- Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS IN TI ORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALT U " INSPECTOR TITLEj7j?j10_iL J j� A.M. DATE TIME ' 1 D 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 II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure'to include shall'in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by'105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by'105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (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. g Y P P 9 (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. l e vs001 a � - FORM3U' HiDWi HOBBSBWARREN'" THE COMMONWEALTH OF MASSACHUSETTS B OARP OF�EA IT z CITY/TOWN u W a DEPARTkENT An )A u5eba ADDRESS }�j T EPHONE Addressc2?8 P�/�� ledkrVlA I ccupan 0 Floor Apartment No. A No.of Occup�nts No.of Habitable Rooms_ _No.Sleeping Rooms /�� No.dwelling or rooming units No.Stories `> _- �,.,��� (..� /e Name and address of owner 0h ��lJ� f ��r, 4%Vyll Remarks vio. YARD Out Bld s.: Fences: q Garbage and Rubbish to V/01 Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing, Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS N.2PE TION ORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENAL J "INSPECTO TITLE J' �j DATE TIME / / L `T` MIf • A.M. THE NEXT SCHEDULED REINSPECTION P.M. ' ,.`• ..h:Y,i rr,, ._rC f,r"'e�'1.:,t":�}•fit ::�:i�r?:'-t� •..R�-'�^•""4i jy.;4't�� .�,.'�,..r ii�--..r-�'S.'hF ..... yw:t:� _ ,-�: ';�bt7"'�;.... � �.. ,...�.i-,.�,::i7"��'y. � _ I 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. . :> � I [FORM30 C&w HOBBSB WARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN DEPARTMENT cY�1- f • ADDRE S �G^M Svyw c � TELEPHONE Address I ��" _ Occupan Floor Apartment No. No.of Occupants No. of Habitable Rooms_No.Sleeping Rooms L__ No.dwelling or rooming units_ No. Name and address of owner AW 3 Storie emarks 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.: IL I ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑Y ❑ N Equip. Repair 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 Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF P 'J Ry." ._'— INSPECTOR TITLE 2, DATE _ '� TIME ' / P M A.M. THE NEXT SCHEDULED REINSPECTION P.M. _ r i 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 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. - Date To Whom It May Concern: 0 I, , voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health (Agent or Health Inspector)to inspect my dwelling unit located at 1�Q� , -j La inaccordance (House#, [Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on 0/,9 70 6 I hereby authorize and name (Date of inspection) "TUb to be my tenant representative for the (Occupant representative) purpose of this inspection. JL is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) J Occupan s Signature \ to ccupants Representative Signature Efate Q:\Rental Ordinance\inspection permission 2.doc ` FORM30 CEw HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD O� TH CITY/TOW W D PARTMENT � cy�1 AD RESS M SV a a TELEPHONE Address a2 Occupant Floor Apartment No. 4 No.of Occupants____ No.of Habitable Rooms_No.Sleeping Rooms j No. dwelling or rooming units No.Stor' s Name and address of owner _ s marks 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: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 ?j Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR TITLE A.M. DATE �ry 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. Date To Whom It May Concern: I, pr voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health (Agent or Health Inspector)to inspect my dwelling unit located at LOT in accordance (House#, [Apt\ nit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on I hereby authorize and name ti ( ate of inspection) �6 h ..PJIQ to be my tenant representative for the (Occupant representative purpose of this inspection. �1 y is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) \ f-7 loe OcCL ants Signature \ ate cupants Representative Signature \ Date Q:\Rental Ordinance\inspection permission 2.doc COMMONWEALTH OF MASSACHUSETTS. F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION SOUTHEAST REGIONAL OFFICE ARGEO PAUL CELLUCCI TRUDY COXE Govemor Secretary opy DAVID B.STRUHS Commissioner c ( September 18, 1998 Mr. W. Thomas Whiteley, President RE:_BARNS_T_AB BWP/ASBES OS W. Vernon Whiteley, Inc. 211 Pine Stre Post Office Box 1266 Maddalena P erty 28 Village Landing ADMINISTRA CONSENT West Chatham, Massachusetts 02669 ORDER WITH PENALTY ACOP-SE-98-R005-C Dear Mr:Whiteley: Enclosed please find an executed copy of the Administrative Consent Order with an Administrative Penalty,ACOP-SE-98-R005-C, regarding the above referenced location. The Effective Date of the Order"is September 17, 1998. The Department appreciates your willingness to resolve this matter, and wishes to remind you of the applicable timeframes for the required actions which are contained in the Order. If you have any questions or concerns, please contact Edward Burke at(568) 946-2768 or at the letterhead address. Very truly yours, ence T. Brennan, Chief Regional Enforcement and Compliance Team(REACT) B/EMB/re Attachment CERTIFIED MAIL # Z 5 9 8 884 126 RETURN RECEIPT'REQUESTED ' ` A 20 Riverside Drive•Lakeville,Massachusetts 02347• FAX(508)947-6557•Telephone(508)946-2700 Printed on Recycled Paper a 2 cc: DEP-SERO ATTN: David Johnston, Deputy Regional Director BWP Christopher Tilden, Regional Engineer BWP Gerald Monte, Chief BWP/C&E Joseph Leary, BWP/C&E Daniel d'Hedouville, Esq. OGC Regional Enforcement Office (2 copies) Board of Selectmen Town Manager's Office Barnstable Town Hall 367 Main Street Hyannis, MA 02601 Board Of Health Barnstable.Town Hall 367 Main Street ' Hyannis, MA 02601 Department of Labor& Workforce Development Division of Occupational Safety Occupational Hygiene Program 181_Hillman Street New Bedford, MA 02740 ATTN: Gary Gaspar Maddalena Family Trust - c/o Robin Maddalena 211 Pine Street Centerville, MA 02632 r. ... COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION IN THE MATTER OF ) RE: BARNSTABLE-BWP/ASBESTOS 211 Pine-Street Mr. W.Thomas Whiteley,President ) Maddalena Property W.Vernon Whiteley,Inc. ) ADMINISTRATIVE CONSENT Post Office Box 1266 ) ORDER WITH PENALTY 28 Village Landing ) ACOP-SE-98-ROO5-C West Chatham,Massachusetts 02669) I. THE PARTIES 1. The Department of Environmental Protection,hereinafter in this document referred to as the'Department",is a ..duly constituted agency of the Commonwealth of Massachusetts("Commonwealth"). Its principal office is located at One Winter Street,Boston,Massachusetts 02108,and a regional office located at 20 Riverside Drive, Lakeville,Massachusetts 02347. The Department is authorized to assess civil administrative penalties by M.G.L. c.21A, §16 and regulations promulgated under.the statute at 310 CMR 5.00. 2. .Maddalena Family Trust;Robin Maddalena (the"Owner"),owns residential property located at 211 Pine Street in Centerville,Massachusetts(the"Site")., 3. W. Vernon Whiteley,Inc.,the Operator("Whiteley),operates a plumbing and heating firm,which does business from 28 Village Landing, in Chatham,Massachusetts 02633. II. STATEMENT OF PURPOSE AND INTENT 1. The purposes of this Administrative Consent Order with Penalty("Consent Order")is to resolve issues of noncompliance pertaining to improper asbestos removal and disposal procedures. 2. The Department and Whiteley are entering into this Consent Order in order to avoid the expenditure of considerable resources in the litigation of this matter. III. STATEMENT OF AUTHORITY AND RESERVATION OF RIGHTS 1. This Consent Order is issued by the Department pursuant to its authorities under: M.G.L.c.142 A-J; M.G.L. c.21 §§26-53;M.G.L.c.21A §16,and the regulations thereunder at 310 CMR 7.00,and 310 CMR 5.00. 2. Whiteley assents to the authority of the Department to issue this Consent Order and waives any rights to further administrative or judicial review of this Consent Order. 3. The Department reserves all its rights to proceed under other laws with respect to all issues other than asbestos. removal and/or disposal,and Whiteley reserves all its rights to challenge any requirements imposed by the Department beyond those set forth in this Consent Order. = 4. This Consent Order is not an admission of liability or a waiver of any defenses which owner/operator might raise in any proceeding to enforce this Consent Order. 2 IV. STATEMENT OF LAW AND REGULATIONS 1. CMR 7.01 -Definitions: Asbestos Containing Material: means friable asbestos and any material containing 1%or more asbestos by weight. This term includes but it not limited to sprayed-on and trowled-on materials applied to ceilings, walls,and ceilings,walls,and other surfaces,insulation on pipes,boilers,tanks,ducts,and other equipment,structural members,tiles,shingles or asbestos-containing paper. Asbestos Containing Waste Material: means any friable asbestos-containing material removed during a demolition/renovation project and anything contaminated in the course of a demolition/renovation project including asbestos waste from control devices,bags or containers that previously contained asbestos, contaminated clothing,materials used to enclose the work area during the demolition/renovation operation, and demolition/renovation debris. Demolition/Renovation' means any operation which involves the wrecking,taking out,removal,stripping, or altering in any way(including repairing,restoring,drilling,cutting,sanding,sawing,scratching,or digging into)or construction of one or more facility components or facility component insulation. This term includes load and non-load supporting structural members of a.facility. Emergency Demolition/Renovation Operation: means any operation that was not planned but results from a sudden unexpected event which requires the demolition/renovation of a structural sound or unsound facility or facility component. This term includes operations necessitated by non-routine failures of equipment. Facili : means any installation or establishment and associated equipment,located on the same,adjacent or contiguous property,capable of emissions;except that for purposes of 340 CMR 7.15,means any institutional,commercial,or industrial structure or installation located on the same or contiguous property, or residential building including single family homes. Facility Component: means any pipe,duct,boiler,tank,turbine,f imace,or structural member located at the facility. Owner/Operator: means any person,any department or instrumentality of the federal government,or any public or private group which: a)has legal title,alone or with others,of a facility,b)has the care,charge, or control of a facility,or c)has control of a demolition/renovation operation,including but not limited to contractors and subcontractors. Disposal: means the final dumping,landfilling or placement of solid waste into or on any land or water or the incineration of solid waste. Solid Waste or Waste: means useless,unwanted or discarded solid,liquid or contained gaseous material resulting from industrial,commercial,mining, agricultural,municipal or household activities that is abandoned by being disposed or incinerated or stored,treated or transferred pending such disposal, _ incineration or other treatment. Effective Date: means the date upon which both parties sign the Order. 2. CMR 7.15(1)(b)-states in part that"any person engaging in an asbestos removal operation must provide the Department with notification ten(10)days prior of the removal activity". 3. CMR 7.15(1)(c)-states in part that"any person engaged in an asbestos removal activity must maintain adequate wetness of the asbestos-containing material("ACM;')to ensure no release of asbestos to the air;and, that once removed,the ACM be sealed in a properly labeled leak-tight container for disposal'. 3 4. CMR 7.15(1)(e)-states in part that"any ACM which has been removed must be properly packaged in a wetted condition;and,must be disposed of at an approved site". V. STATEMENT OF FACTS 1. On November 3, 1997,the Department received a complaint alleging that an illegal asbestos abatement was being performed at the Site by an unlicensed company. 2. On November 7, 1997,the Department,accompanied by the Department of Labor and Workforce Development(DLWD),conducted an inspection of the Site and observed a cardboard box with a black plastic bag over it.The box contained over three(3)linear feet of friable ACM. The Department determined that-the ACM had been removed from six(6)pipe joints in the basement of the building. The Department also determined that Whiteley had conducted a plumbing repair job. 3. Department records indicate that there was no prior notification to the Department of the abatement operation, in violation of 310 CMR 7.15(1)(b). Further investigation revealed that the ACM had not been wetted,and had not been properly handled and containerized, in violation of 310 CMR 7.15(1)(c)&(e). DLWD had taken four (4)samples of ACM. 4. On November 10, 1997,the Department received analytical results of suspected asbestos samples taken by DLWD on November 7, 1997. All four(4)samples were positive,ranging from 45%to 60%Chysotile Asbestos. 5. On November 24, 1997,the Department received Emergency Asbestos Removal Notification from Air Safe International,Ltd.Asbestos Disposal Company of Norwood,Massachusetts, indicating that they have been hired by the owner in order to remediate the Site. The notification form indicated that the Site would be decontaminated,and that the ACM waste would be wetted,bagged, and disposed of at a properly licensed facility.. VI. DISPOSITION 1. For the reasons set forth in Sections IV and V above,and pursuant to the authority granted to the Department,the Department hereby issues and enters into this Consent Order with Whiteley 2. The terms and conditions of this Consent Order shall take effect on the Effective Date of this Consent Order. 3. This Consent Order is issued under authority of M.G.L.c.21A, §16 and asserts that,for having violated the requirements contained at 310 CMR 7.15,agrees to comply with the terms contained in this Consent Order. This Consent Order specifies the actions and deadlines necessary for Whiteley to achieve and maintain compliance. 4. Whiteley's compliance with all the terms and conditions of this Consent Order shall constitute full and final resolution of all matters relating to the improper removal and/or disposal of ACM generated at and/or from the 211 Pine Street in Centerville,Massachusetts,as observed on November 7, 1997. Future ACM abatement projects by _ W.Vernon Whiteley,Inc.,(and/or its subcontractors,heirs,assigns,etc.)shall abide by all necessary requirements as denoted in 310 CMR 7.1.5(as applicable). 5. The Department is not aware of any industry conditions or pending legislative or regulatory changes which would effect the applicability of this Consent Order. r 4 VII. PENALTIES 1. Within thirty(30)days of the Effective Date of this Consent Order,Whiteley for having violated the provisions of 310 CMR 7.15(1)(b),(c),and(e), shall pay a Civil Administrative Penalty to the Commonwealth in the amount of four thousand seven hundred dollars($4,700.00). Payment must be by certified check,cashier's check,or money order payable to the Commonwealth of Massachusetts,Department of Environmental Protection. The name, Whiteley and the Consent Order File Number,ACOP-SE-98-R005-C,should be clearly printed on the face of the check or money order. Failure to do so could delay accreditation of your payment and compliance status. The remittance should be sent to: Commonwealth of Massachusetts Department of Environmental Protection P.O.Box 3584 Boston,MA 02241-3584 VHI. STIPULATED PENALTIES 1. If Whiteley fails to comply with the penalty payment as described above in Section VII,such that the penalty is not paid in a complete or timely manner,Whiteley shall,pursuant to M.G.L.21A, section 16,p 11,be liable to the Commonwealth for up to three(3)times the amount of the unpaid penalty installment,together with costs,plus interests at the statutory rate from the date the penalty payment installment becomes due,inclusive of attorney's cost and fees directly incurred in the collection of the described penalty installment. 2. All payments of stipulated penalties shall be by certified check,cashier's check or money order,made payable to j the"Commonwealth of Massachusetts"and shall contain the name,W.Thomas Whiteley,and the Consent Order Number,ACOP-SE-98-R005-C. All stipulated penalty payments shall be sent to the following address: Department of Environmental Protection Box 3854 One Winter Street Boston,MA 02241-3584 , IX. SUMMARY 1. Whiteley shall not violate this Consent Order,and shall not knowingly allow or suffer its employees or agents to violate this Consent Order. This Consent Order shall apply to and be binding upon and shall inure to the benefit of the officers,agent,successors or assigns. 2. The undersigned represents that he/she has the authority to bind Whiteley to this Consent Order. 3. The Department represents that the Regional Director has the authority to bind the Department sign this Consent Order on behalf of the Department with respect to this Order and all applicable statutes and regulations. _ 4. Each document submission required from Whiteley by this Consent Order shall be submitted to the Department, to: Edward Burke Department of Environmental Protection b. Southeast Regional Office 20 Riverside Drive Lakeville,MA 02347 5 X. SIGNATURES AND EFFECTIVE DATE 1. This Consent Order shall become effective upon the date by which it is signed by the Department. W.VERNON WHITELEY,INC By: Date: Q' 3 W.THOMAS WHITELEY, P SIDENT i FEIN No. DEPARTMENT OF ENVIRONMENTAL PROTECTION By: Date: Paul A.Taurasi,P.E. Regional Director i COMMONWEALTH OF MASSACHUSETTS Z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION SOUTHEAST REGIONAL OFFICE '�M Sve ARGEO PAUL CELLUCCI TRUDY COXE Governor Secretary DAVID B.STRUHS OD Commissioner August 27, 1998 Mr. W. Thomas Whiteley RE : BARNSTABLEE-BWP/AQ/ASBESTOS W.Vernon Whiteley, Inc . 21.__ 1 Pine Street Post Office Box 1266 Maddalena Property 28 Village Landing ADMINISTRATIVE CONSENT West Chatham, Massachusetts 02669 ORDER WITH PENALTY ACOP-SE-98-R005-C THIS IS AN IMPORTANT NOTICE. FAILURE TO RESPOND TO THIS NOTICE MAY RESULT IN SERIOUS LEGAL CONSEQUENCES. Dear Mr. Whiteley: On May 19, 1998, the Department of Environmental Protection (the "Department" ) conducted an enforcement conference at its Southeast Regional Office concerning an improper asbestos removal action which was performed by you (as used in this letter, "you" refers to W. Vernon Whiteley, Inc. ) at the Maddalena property located at 211 Pine Street, Centerville, Massachusetts, (the "Site" ) . The conference was conducted in order to negotiate a mutual settlement between yourself and the Department regarding the issues of noncompliance . Enclosed, for your. review and signature, are two copies of the Consent Order which require the payment of a penalty in accordance with .the agreement reached at the settlement conference on May 19, 1998 . If the document is acceptable to you, please sign both copies and return them to the Department for execution. If you fail to sign the Consent Order, the Department will initiate unilateral enforcement action and you will have limited future opportunities to negotiate a consensual settlement with 20 Riverside Drive•Lakeville,Massachusetts 02347• FAX(508)947-6557•Telephone(508)946-2700 This information is available in alternate format by calling our ADA Coordinator at(617)574-6872. DEP on the World Wide Web: http://www.magnet.state.ma.us/dep K,Printed on Recycled Paper 2 i the Department . Once signed by both parties, the Department will return an executed copy to you for your records . Please contact Edward M. Burke at 508-946-2768 or at the letterhead address within seven (7) days of your receipt of this letter regarding your intent to sign the Consent Order or if you have any questions regarding the document . Sincerely, Richard J. Gioiosa Regional Enforcement -Office G/EMB/re . Attachment CERTIFIED MAIL # Z 598 884 837 RETURN RECEIPT REQUESTED (Cover Letter Only) CC : DEP-SERO ATTN: David Johnston, Deputy Regional Director BWP Christopher Tilden, Regional Engineer BWP Gerald Monte, Chief BWP/C&E Joseph Leary, BWP/C&E Daniel d'Hedouville, Esq. OGC Regional Enforcement Office (2 copies) Board of Selectmen Town Manager' s Office Barnstable Town Halle' 367 Main Street Hyannis, MA 02601 Board Of Health Barnstable Town Hall 367 Main Street Hyannis, MA 02601 3 CC : Department of Labor & Workforce Development Division of Occupational Safety Occupational Hygiene Program 181 Hillman Street New Bedford, MA 02740 A,'TN: Gary Gaspar Maddalena Family Trust c/o Robin Maddalena 211 Pine Street Centerville, MA 02632 P � Z1� %�� S ����� ���� ���� i -- COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION SOUTHEAST REGIONAL OFFICE e ARGEO PAUL CELLUCCI TRUDY CORE Governor F CO Secretary DAVID B.STRUHS Commissioner IY April 30, 1998 Mr. W.Thomas Whiteley RE: CENTERVILLE—BWP/AQ/ASBESTOS W:-Vernon Whiteley, Inc. 211 Pine Street Post Office Box 1266 Maddalena Property 28 Village Landing NOTICE OF ENFORCEMENT West Chatham,Massachusetts 02669 CONFERENCE AND "draft" PENALTY ASSESSMENT NOTICE THIS IS AIN IMPORTANT NOTICE FAILURE TO RESPOND TO THIS NOTICE MAY RESULT IN SERIOUS LEGAL CONSEQUENCES Dear Mr. Whiteley: On November 7, 1997,the Department of Environmental Protection(the "Department") conducted an inspection of an asbestos abatement project which was performed at 211 Pine Street in Centerville, Massachusetts (the"Site"). The inspection was performed in response to a complaint which alleged that an asbestos removal action was performed improperly and without notifying the Department, resulting in potential contamination of the family residence and the involved asbestos removal workers. The inspection revealed that several pipe joints were repaired by you(as used in this letter, "you" refers to W. Vernon Whiteley,Inc.),which resulted in the removal of asbestos from the pipe joints. During the inspection,the Department observed suspected asbestos containing material ("ACM") on the floor and in a cardboard box with a black plastic bag around it. Department regulations contained at 310 CMR 7.1 5 stipulate that the removal of ACM must only be performed in an enclosed area, in a wet fashion, and that the removed wetted ACM be properly containerized and prepared for proper disposal. Department regulations also require that prior notification be given to the Department at least ten(10) days prior to engaging in the ACM removal activity. In addition, it is required that this ACM activity be performed by a qualified person who is certified and licensed by the Massachusetts Department of Labor and Workforce Development, Division of Occupational Safety,Occupational Hygiene Program. 20 Riverside Drive•Lakeville.Massachusetts 02347• FAX(508)947-6557•Telephone(508)946-2700 �, Printed on Recycled Paper r 2 A review of Department records shows that you did not submit an asbestos notification to the Department concerning the ACM removal project,thereby constituting a violation of the regulations contained at 310 CMR 7.15(1)(b). Since the Department observed the presence of ACM scattered around the Site, the Department determined that the removal, handling, and containerization requirements for ACM were.not followed,thereby constituting a violation of the regulations contained at 31.0 CMR 7.15(1)(c). As a result of the Department's investigation the Depa' tment�now intends to take 0- '. 1 enforcement action against you in regards to these noompliance-issuegt;P ssible enforcement nc actions include, but may not be limited to the following: (a) issuance of an ADMINISTRATIVE PENALTY; (b).an ENFORCEMENT ORDER; and/or(c)Referral of the matter to the Massachusetts Attorney General's Office for prosecution. However,prior to proceeding with such actions, you are asked to attend an enforcement conference at this office on the following date and time: DATE: Tuesday, MAY 19, 1998 TIME: 10:30 a.m. LOCATION: Department of Environmental Protection Southeast Regional Office 20 Riverside Drive Lakeville, Massachusetts This conference will provide you with an opportunity to reach a negotiated agreement with the Department concerning compliance and the.payment of an Administrative Penalty. You must send a representative to this meeting who is fully empowered to resolve this matter on your behalf. At the conference, you may discuss the alleged violations, and the requirements and penalty conditions of a negotiated settlement. Prompt resolution of this matter through a negotiated settlement is beneficial to both parties, consistent with the Department's environmental goals, and limits resources otherwise expended on litigation of the issues. Be advised, if you do not attend the enforcement conference and reach a negotiated settlement and the Department initiates further enforcement action,you will have limited future opportunities to reach a negotiated settlement of this matter. Attached is a"draft" Penalty Assessment Notice("PAN") which addresses-your role and responsibilities in this matter. Please be advised that the PAN may be issued unilaterally should you fail to attend the conference and reach a negotiated settlement with the Department. Please notify the Department within five(5) days of your receipt of this Notice regarding your intentions concerning attendance at this conference. Should there be any questions regarding this matter,please contact Edward Burke at 508- 946-2768 or at the letterhead address. E 3 Very truly yours, nce T. Brenilan,'Chief Regional Enforcement and Compliance Team (REACT) In accordance with the Americans with Disabilities Law,for special accommodations for this meeting,please contact John Viola, Deputy Regional Director of Administration at.508-946-2703 as-soon as possible. B/EMB/ka Attachment CERTIFIED MAIL NO. Z 333 585 820 RETURN RECEIPT REQUESTED cc: (Cover Letter Only) Board of Selectmen Town Managei's Office Barnstable Town Hall 367 Main Street Hyannis, Massachusetts 02601 Board of Health Barnstable Town Hall 367 Main Street Hyannis, Massachusetts 02601 Department of Labor& Workforce Development Division of Occupational Safety Occupational Hygiene Program 181 Hillman Street New Bedford, Massachusetts 02740 ATTN: Gary Gaspar Maddalena Family Trust c/o Robin Maddalena 211 Pine Street Centerville, Massachusetts 02632 4 cc: AirSafe International, Ltd. 61 Endicott Street Norwood, Massachusetts 02062 DEP-SERO ATTN: Christopher Tilden, Regional Engineer BWP Richard Gioiosa, Regional Enforcement Coordinator Gerald Monte, Chief B WP/C&E Joseph Leary, BWP/C&E Laura Patriarca, BWP/FMF cc:-(Cover Letter and Attachment) DEP-SERO ATTN: David Johnston..Deputy Regional Director, BWP Daniel d'Hedouville, Legal Regional Enforcement Office TOWN-OF BARNSTABLE LOCATION o2// �/�2 � SEWAGE # ��Y- 9 g5- VILLAGE ASSESSOR'S MAP & LOTaq 9-60`1•601 INSTALLER'S NAME & PHONE NO./411 e,�nc0 P7 5-- O?eoo SEPTIC TANK CAPACITY Z 000 LEACHING FACILITY:(type) ,F Zia( TRH 9(size) X X 3 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERff DAT&PERMIT ISSUED: DATE COMPLIANCE ISSUED: a VARIANCE GRANTED: Yes No I _� 1y� ._C: � � � \ _ �, �, �. , . � � �� f o_ ��., ��� �' ,- ... If 11 No...l. .............`r. Fps............�...... ... THE COMMONWEALTH OF MASSACHUSETTS 0© BOAR® OF HEALTH b. TOWN OF BARNSTABLE Ap.pliratiutt for Diri.pwial Workii Towitrur#inn jinutit Application is hereby made for a Permit to Construct ( ) or Repair ( —j-an Individual Sewage Disposal System at: °n Location-Address or Lot No. 1fL .................................. ................................................................................................. Owner Address Installer Address UType of Building Size Lot............................Sq, feet ►., Dwelling— No. of Bedrooms...........- ...........................Expansion Attic ( ) Garbage Grinder ( ) 111 Other—Type of Building -----=---------------------- No. of persons.-----------.--------.------ Showers ( ) - Cafeteria ( ) Q' Other fixtures -------------------------------------------•---. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacity........---.gallons Length---------------- Width...--..--....... Diameter....------------ Depth.............. Disposal Trench--No. .................... Width.................... Total Length.----............... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...................- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) � Percolation Test Results Performed by.......................................................................... Date........................................ ,,-a Test Pit No. I................minutes per inch Depth of Test Pit-----......--....... Depth to ground water.....................--. fl, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ....-------•----.......•--•---------------•-----------------------•----------------......-•-•--........-----------•-•--------------•--•--.._.........--.•.... 0 Description of Soil...................................................................................... ------------------------------------------------------------------•-•---•--...---• x U -••••••••-••--------•---...•----••••-••••-•----------••---------------------------••..........----•----•-•••------------•----------•-••••............................................................. x ••• ------------------------------••---••--•----...----------............•-•••----------------•-----------••--•------------------------....-•-••-••-••-•--•--•------•--------•---------.--.---.------. U Nature of epairs or Alterat•ons .Answer when applicable.10,51n.1t-----I- -aC,Qo.... � �, 7t!.S=.....'�e� ---------�? !''......----•..................•-......---••-•-•---.... 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 Compliance has ben issued by the board of health. A. Application Approved B /.......... ... ........... .. . Ali........ Dare Application Disapproved for the following rew-ons: ................ . ........................................................----..................................... .................... ................................................ -- ........................................................... . . -------------------------------------. ........................................ I —� `„�� Date Permit No. ............... Issued Dare . ter3� �y No........... - n Fss.............................. 0 ( THE COMMONWEALTH OF MASSACHUSETTS C/ BOARD OF HEALTH TOWN OF BARNSTABLE Apphration for Biopoiul Hi,ar1w Tonitrnrtion Ilerra t Application is hereby made for a Permit to Construct ( ) or Repair ( —�an Individual Sewage Disposal System at: - ------- -------i1�....--- #......---•---------------------•---....... P h �/. Location- Address or Lot No. .....i�1�_Gt_ _C?. .........r's ...................... ... N ............•.................. - 1 Owner Address a �.Q C <7 ...... ................................ Type of Building Installer ` . Address Size - Sq. feet Dwelling No. of Bedroom s............ _________________-_---_Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons........................... Showers ( )`— Cafeteria ( ) dOther fixtures ......................................................-------------------------•-------...-------•---••---------------............t:................ 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.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date........................................ ,.� 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........................ 94 •-••-------•...............•---•--••---••--•--•.............---•------•-•--••-•.....-------•---------------------------------------------- ................ •-- 0 Description of Soil........................................................................................................................................................................ x V W U Nature of Repairs or Alterations Answer when applicable_ 0.). 6_(1___-_I _ 416 A.... ief l:-••-,si'p ew: ...... 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 Compliance has been issued by the board of health. Y Signed .. .._..._.. �" 2�_" Application Approved By----..,.=_ ,�..........:.............. :.... � �t . ...r Dae Application Disapproved for the following reasons: ... ............... ............................................................................................................. ................... .................................................. ... ................................................... . . ......................--............ -- . ........................................ Q Dare PermitNo. l . -r,�.............. Issued ........................................................--.......... Dace ,s.—a-.—=-?- .ems..—.c.:—a.<_a u,—— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tl.� i n ertifirate of U.ompltre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( L.,;)— by ............................... -----------------------------------------...---.-.. -.-..----------------------.-----.-.-.----------------.....-_.-.-....--------------------------..-..-------..... at ....... ................ %���' � t---- -_-......--.....1...�....../�-i/i`c ..................................... has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -�.1_/.-_qS'S .... dated .... _. . ...rZ .. - ........... THE ISSUANCE OF THIS CERTIFICATE SHALL-NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................... .................��--------------------- ........ Inspector ........ � .__..._.-.."- ....--- ...................--- ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.. ......y.. FEE .................. �ts�oottl orlao �onotr�rtion �erntit Permissionis hereby granted--------------- i4flT ------------------------------------------•----------------------------------------•---- to Construct ( ) or Repair (—) an Individual Sewage Disposal System at No. Viz- �--_l.o ��-----•••--• � fci- .' ��t_._.. .. ..._.__ street ty as shown on the application for Disposal Works Construction Permit N = .5Dated... _,/_..1:_._-..._.___............... ..__ Board of Health DATE.. '---• •-••-•-•-•-----•----•---•-- FORM 36508 HOODS 6 WARREN.INC..PUBLISHERS r-C�O e> C S• .L TOWN.OF BARNSTABLE LOCATION r �I '� '`� �� �-L'1 ' S SEW AGB - �� VILLAGB ,vile✓'vll1w, ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY I 700 Cu LEACHING FACILITY:(type) Co-.ajj > (size) _ NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER BUILDER OR.OWNER DATE.PERMIT ISSUED: /® - • 9/ DATE; COMPLIANCE ISSUED-.; VARIANCE.GRANTED:: Yes. No�� r ,� �� � � �� �-� ��e No...41.."--�0%d 2� Fps.. ................ HE COMMONWEALTH OF MASSACHUSETTS BOARD OF H EA La�rll � n TOWN OF BARNSTABLtaba c.�j p R o v , wort,,, D Appliration for Dhipvii al nrkii Can 'un rmit,1ss toh Application is hereby made for a Permit to Construct ( ) or Repair man Individ wa a Disposal System at: ... P ..3�J 1�c. ���` ... .-... C-Ll o.%T..�Z�..�........CC tiq e/Z 1 L_L <� a t© Location-Addr ss . - 0 N i.3 S'S' L C N ff i 1 A J 1�i LT' V' t l= cT 12 V ie L Owner Address ................. ------ ^ -lo............................................ TAQ --� ....9? ---�...... = .t�.----... Installer Address Type of Building Size Lot.................... Sq. feet Dwelling&Z No. of Bedrooms___.----- A•-:•--___-•_-•-___•__-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 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.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r%4 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ 0 a ..........-................................................................................................................................................... Description of Soil...............................................................................-------------------------------•----------------------------•----•••----.........-----•- x w U Nature of Repairs or terations—Answer when applicable._ _ ________________� ..�'1 .! ............ ............... 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— he�indersigned further agrees not to place the system in operation until a Certificate of Co pnpll n s been issue b the board of health. F Signed --- ................ ----- -------------- ----............................................ ---9 --9 r g I- ---- - --- ---- � Date Application Approved By ..........�J (,.. ��..-.r-- .... Dare Application Disapproved for the following reasons: ............................................ . ... ................ . ............................... ................ .. --------------------------------- -- ------------------------------------------ --- ---- ----------- -------------- ----------------------- - ---------------------- ---------- --------------------.................. PermitNo. ...-- -el........����- -------------------- ------ Issued .......................................................I Date....-- - Dace No.. , /=...Ll THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apptiratiou for Uiipuiial WorksCn�n r �rtiun rruti Application is hereby made for a Permit to Construct ( ) or Repair (/ 1an Individual,'Sewage Disposal System at: �� y C n _-)!?:.. :!!�?r Y"`J, '1....(�C_C.I.!Z.7� ../21�..: � � �?7 �.r1.��_�_(_:_!:_<� � ............... -•-••-•-- ••..... ------------------.....------...... ........ - Location-Address or.Lot No. ....... �". ...._. - �4........ W Owner Address� ___•........................ Installer Address Type of Building Size Lot............................S4.'feet aDwelling--Z' No. of Bedrooms......-'% ___________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) A4 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.................... 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........................ �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----.__-__---__-.._-_- -------------------------------•-------•--------•------------------•-•--•---••••-••...........----•......................................................... ODescription of Soil........................................................................................................................................................................ W V ................•---------------•---•---•-•-----•••-•-••--••-•-••••---•••------•-------....................................,........................................................................... W UNature of Repairs or Alterations—Answer when applicable X� _-_1 off? q---- �_n !.c.... *. ............ -------------------------------•--- 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 Co p iance,has been issued by,'the board of health. Signed --. v� ? ............................................. ....?...... -9. --g .. Date Application Approved BY ` -...--^-.....`� ------------------------ ---- �/...- Date Application Disapproved for the following reasons- - ------------------------------------------------------------------ --------------------- ------------------------ ---- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ........................................ Date Permit No. .---...?/— -----L/-_3. Issued ---------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#ifi ate of Tomplittnce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by .......... ......---- --------------- ------------------------- l ------- Instaler e p -- at ....... .ra.. 1 � 71 .L.l 1- ..:.......... .1 a ?..('.1l-/r,f�l---. -------------------...- has ben installed in accordance with the provisions of TITLE 5 o£,The State Environmental Code as described in No. the application for Disposal Works Construction Permit .-----.�--` ...... ..a- ...... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATEl_ t.f---------------------------------------------------- Inspector .. ......... ........................-:.---...----------------------...................... 1 f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No..��=• Lj FEE.....: ©:.. Rapagttl rk ��aa� r r#irrn ernti Permission is hereby granted R fa.. ? r- ?--------------------•----•-----------•-....------......-----..........••••....---.... C/ to Construct ( ) or Repair (L,)-an Individual Sewage Disposal System O at No.-•---1 U• .....'s_,t ...... t 9 (=C_4.::f.o ....!. �" =x.x' K ?_1.� t " •--------------------------- Street as shown on the application for Disposal Works Construction Permit No?:-:. Dated.......................................... •.................•---••-•-•----- r ----- ;------------•----....--------....---...._ D �ATE............... e......................................... Board of Healfh t�•=-�---•-,! FORM 36508 HOBBS&WARREN.INC..PUBLISHERS ASSESSORS MAP :,_ ` TEST H0 _ E LOGS PARCEL.: �d NOTES: v,4k- CSP--Ei:T FLOOD ZONE: Ad6l 4FFUC10 SOIL EVAL - 'I : ) VI M 1 The W I TNES i-=---' ) installation shall comply with Title V and Town of Barnstable Board of �- Health Regulations. REFERENCES , t>,P' r -�'L DATE: �Vla,(_._�?. , 2C71 Z PERCOLAT—ION )RATE: L Z Wtt�vl, IL.� 2) The installer shall verify the location of utilities sewer inverts and septic p C'U 7, '�^ - — components prior to installation and setting base elevations. TH- 1 TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first two feet out of the d-box to the leaching shall be level. 1,D5 o � 4) This plan is not to be utilized for property line determination nor any other ��, lo� i "�L 1 purpose other than the proposed system installation. I`D 10X 5) All septic components must meet Title V specifications. �, y 1-1-1 . .,.. 6) Parking shall not be constructed over H10 septic components. ' 1 . 7 The property is bounded b property LOCATION MAP �.._ .�� � �.—_._ _ p,� ) P p Y Y p p y corners and property lines. 21 — 8) The property owner shall review design considerations to approve of total t,G1 Ir y T 1 � design flow and number of bedrooms to be considered for design. Receipt ll l of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. )) The existing leaching or cesspools shall be pumped and filled with material PINE 4CPU81-IC WAY) s`,'�� _ � � '� per Title V abandonment procedures. Those within the proposed SAS shall I � _ ��'� �� t be removed along with contaminated soil and replaced with clean sand per • ate" 902.86 NO Jl,�t 1-l° qmo W � Title V specs. S�'p,5 — --- P Q 7• I I 675� ,,. �fC � (�bZ 10)System components to be 10 feet from water line. Sewer lines crossing the ••� water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if `,� �° _ __1._- Z I �► SEPT I C SYSTEM DES I G N applicable. The proposed SAS is being installed below the water service I I maintained line. The line is to be sleeved as aforementioned and mai�----__ d in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW ESTIMATE owner to ensure such. BEDROOMS AT GAL/DAY/BEDROOM - tAb0GAL/DAY exists.12) installer is to take caution in excavation around the gas line if such I -n't _- 13)The installer shall verify the location, quantity and elevation of the sewer 5 i - - ---- SEPTIC TANK '�u�fLLl.l�►-� s5 lines exiting the dwelling prior to the installation. O or -�,' 1iX}��1r1-1If SAL/DAY x 2 DAYS - 1 GAL USE L!1�bb GALLON SEPTIC TANK _:�C�'eXV4�,__ 6►Qk,4VM OCT SOIL ABSORPTION SYSTEM �r ° M , 500 4� L, 2t-tkiJ�� VDTl�-1 '; � v _ (� I \a AIN/1 � U J _ r'VIM, r IDI — SIDE AREA: C _ \q , BOTTOM AREA: ► II 6210(o 01 3 0 Ar SEPTIC SYSTEM SECTION CO C1 ff `~' I �C,1.5T��tC� ��C. � � � �( D+4-�1 ��!►� _ �' � M1 �� ,w�----._......_•._..-..._ �M�"� n a / �/44; R CO °p t GAL 1 `� pn I-- { ..r__ i..p..-1 I� � co M O SEPTIC TANK 1. �� �f.- -� ►�- 7 �� ux * p - w 12,$-5 144;64- -�- v,80! 57-' �5�W - P SITE AND SEWAGE PLAN LOCATION : T t16 ,q lberfi ' PREPARED FOR : P M SCALE: DAV I D B . MASONIR5 DATE: Z _ DBC ENVIRONMENTAL DESIGNS z EAST SANDWICH. MA W DATE HEALTH AGENT ( 508 ) 833- 2 177 Z 1503 GALLON TANK DISTRIBUTION BOX 500 GAL CHAMBERS - 'H10 CROSS SECTION LOCUS PLAN NOT TO SCALE NOT TO SCALE NOT TO SCALE NOT TO SCALE NOT TO SCALE 38.3 MIN 25 COVER TO BE WITHIN 6"OF GRADE MAX.36"COVER 2" 1/8"-1/2" WA DIED STONE 4"SCH,40 P.V.C. 3"MAIM - 4"SCH.40 P.V.0 •Y/ / 13" o 0 0 E� C� O EE E7 LO C� O C� O 0 0 0 0 0 0 0 0 0 0 �_ .::..::::. 34 3 -r „ 33.75 32.85 / - 9' 4 11 ... / - ...... \ (��`'�>;iik`6iifiF<`;'ci;:;i<?'<.. ..::3�:�:i;i: .`ii;�:Z•:>i:ii:;::;':.: $4 Iy o 0 33.1 0 � o 0 0' o 0 0' o o c:rn I o � s r 2 0 � S \ o0000 � ,� a a o / , o 0 0 4.0 32.94 30.85 � � � � 0 � 0 � � � �_.� >::;: � R MIN 3. 25.5'WITH Y ON EITHER SIDE OF CENTER UNIT 3.5 31 4 83 3' t s;�sii : ;:: ::,:::::j 38.5' 10.83' 10.5' 3/4"-1 1/2"DOUBLE WASHED STONE _BOTTOM OBS 24.1 SITE SPECIFIC NOTES _ DESIGN CALCULATIONS GENERAL_ NOTES F1.,00R 113L�,(�iN t � ALL PIPING TO BE SCHEDULE 40 P.V.C. CESSPOOL(S)TO BE PUMPED&FILLED EXISTING BEDROOMS 4 0 110 G.P.D. ALL LOCATIONS OF UTILITIES SHOWN ARE AS C'B FIRST FLOOR 440 G.P.D. MARKED BY DIG-SAFE AND ARE TO BE VERIFIED BY INSTALLER PRIOR TO INSTALLER TO NOTIFY DESIGNER 24 HOURS CONSTRUCTION PRIOR TO BEGINNING OF JOB TO DE H BELONITSW 4 A DEPTH BELOW INV. 2' THERE ARE NO KNOWN WETLANDS WITHIN COORDINATE INSPECTIONS 8`�� WIDTH 10.83' 150' OF THE Pi<OPOSED LEACHING FACILITY -p ,E. LENGTH 38.5' UNLESS SHOWN PINE THERE ARE NO KNOWN POTABLE WELLS WITHI SIDEWALL AREA 197.3 100' OF THE PFOPOSED LEACHING FACILITY. BOTTOM AREA 416.96 76.J4� UP TOTAL SQUARE FEET 614.26 SF THERE AORE NC.[.KNOWN IRRIGATION WELLS 4 WITHIN 50 OF IHE PROPOSED LEACHING CAPACITY SIDEWALL 00.74 146.0 G.P.D. FACILITY J� BATH CAPACITY BOTTOM ® 0.74 308.5 G.P.D. THIS PROPERTY DOES NOT FALL WITHIN A BEDROOM LIVING ROOM CAPACITY TOTAL 454.55 G.P.D. FLOOD ZONE AS' SHOWN ON FIRM MAP J HIS DESIGN DOE-3NOT REQUIRE VARIANCES T j TITLE 5 (310 C.M.R. 15.00) -0R BARNSTABLE O THIS SYSTEM NOT DESIGNED TO SUPPLEMENTAL REGULATIONS. .�I ACCOMODATE A GARBAGE ALL CONSTRUCTION SHALL BE IN ACCORDANCE DINING ROOM DISPOSAL REGULATIONS TH TITLE 5 AND BARNSTABLE SUPPLEMENTAL CyG CAI BEDROOM KRCHEN -' CD YV IN-LINEELEVATIONS PROPOSED AS-BUILT SURVEYIl'JI'ORMATION C1P CD INV. 0 HOUSE 34.3 PROPERTY LINE DATA FROM ,i INV INTO TANK 34.0 Nickerson and Berger INV OUT OF TANK 33.75 Subdivision Plan 12422C 2ND FLOOR .15 S INV INTO D-BOX 33.1 PLAN TO BE USED FOR INSTALLATION INV OUT OF D-BOX 32.94 OF SEPTIC SYSTEM ONLY INV INTO CHAMBER 32.85 1�. BOTTOM OF CHAMBER 30.85 NOT FOR DETERMINING PROPERTY LINES \`s BATH _ ' .,.. ngg I„II F a4.1_ BENCH MARK\ --- - ii TOP of 5>no 'tube 35.8 (ASSUMED) i ,t WATER TABLE NONE ENCOUNTERED I - -5- #21 cr DATE: OBSERVED BY: WITNESSED BY: SOIL LOGS LISA C. LYONS DONNA MIORANDI BE�o NYC DUNE 1, 2008 SOIL EVALUATOR L BOARD OF HEALTH BEDROOM car port TH ELEV. DEPTH ELEV. OBS. HOL �PTTI OBS. HOLE #1 O i x 36.1 0„ 36.3 _ 0„ under deck { A LOAMY SAND A LOAMY SAND i 1 OYR 4/3 1OYR 4/3 TH 2 t 34,9 B LOAMY SAND 4„ 35.114 -- 4„ �`► B IC A.MY SAND T AS SPECIFICATION S 33.6 V _ l OYR 5/3 31" 33.97 10YR 5/3 2811 C MEDIUM SAND a �' 3 500 GAL CHAMBERS WITH T S 54TONE 2.5Y 5/6 4 " C :F2Y SAND " 2.5.SY 5/6 ` BETWEEN;3.5'ON ENDS AND TON SIDES. BENCHMARK SET `., OVERALL DIMENSIONS: 38.5 X 10.83 24.1 top Of sona tUbP NO GROUNDWATER ENCOUNTERED 44" 24.3 _ 44� • NO GROUNDWATER ENCOUNTERED El, 35.8 00 INSTALL 40ML VINYL BARRIER AS SHOWN PERC RATE<21v1IN/INCH m NGWE @ ELEV 24.1'. PER GIS,IP WETLAND AT OR BELOW ELEV 2o,ADJUSTED GROUNDWAI7ERAT i ELEV 22.8' (WELL MIW 29;ZONE Q �� ERE QU S E T MINIMUM 8.o5'SEPARATION PROVIDED No VARIANC SETBACK1TO FOUNDATION. 15'PROVIDED;20' 00 REQUIRED. 5'VARIANCE REQUESTED. 2)230 INSTALL 40ML VINYL BARRIER AS SHOWN 1 ^S q •, SEWAGE DISPOSAL SYSTEM �` s 0 Tg 08, '08 N42 LDS�NS �= FL PROPOSED SEPTIC SYSTEM REPAIR IN&kRNSTABLE ' AVi\iJ O i tr O 1 FOR: DRAWN 9Y: LISA C. LYONS 7 v �,C, '� �� JEAN SCHABLIK LISA C. LYONS . �� DESIGNED & CHECKED BY: i� .� �O• �`� LOCATION: 4 '�i,��c'••�;;;;::Q•' ��.� 21 PINE TREE DR CENTERVILLE v121 P�T"E DR I�: DESCRIPTION: DATE: I/rER1111Q A�,��+ { 7 LOT P142 DATE: 1g 200� FLOOR PLAN 7 7 08 SCALE 1 . 2 0 A C��S' .S.S. I CERTIFY THAT THIS PLAN CONFORMS TO LISA C . LYONS, I \p , S, (508) 790-9270 TITLE 5 AND BARNSTABLE B.O.H. REGULATIONS (774) 487-1638 (EXCLUDING WAIVERS SPECIFIED) HYANNIS, MASSACHUSETTS