HomeMy WebLinkAbout0133 BETH LANE - Health 133 BETH LANE, HYANNIS
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BARNSTABLE,
Regulatory Services
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�A 1639. Public Health Division
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Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax:.508-790-6304
CERTIFIED MAIL#7014 1200 0001 0358 0048
January 18, 2017
Mr. and Ms. John and Sandra Hibbard
4 Terrace PI
Roxbury, MA 02120
DWELLING REMAINS UNFIT FOR HUMAN HABITATION AFTER RE-
INSPECTION
On January 17, 2017,the dwelling owned by you located at 133 Beth Lane Hyannis Massachusetts was
re-inspected by,Thomas;McKean,.R.S., Health Agent for.the Town of Barnstable and Bill Rex,Fire
Inspector for the Hyannis Fire District. The following violations were observed:
410.482: Smoke detectors not operational in basement.
410. 500: ,Broken fronf.storm door no window'pane in.storm door.
410.602 (B): Excessive mold and multiple spider webs observed on.ceiling inside the multiple
debris filled closet located in living room.
410.402 B): Strong foul odors detected in second bedroom to right(old stained carpeting
remains on floor where the dead cat was observed) and strong odors detected in last bedroom at
J right.
410,602 B): Feces observed on floor in basement where multiple cats were observed.
4:10.500: No window pane provided in basement window;;cats-entering and exiting through the
opening adjacent to air conditioner.
410.500: Multiple areas of rotted wood observed at exterior along bottom of windows. .
410.452: No handrail provided of left side of front door stoop,
Q:Order Letters/Condemnation/133 Beth Lane Reinpection 2017.docx
410.452: The right hand rail at the front doorstop was very loose and rusted at bottom.
410.351: Electrical cover plates were not provided at multiple light switches and outlets
(removed during painting work).
410.450: Two rooms were observed in the,basement that do not provide adequate second means
of egress. .
Based upon these findings,this dwelling remains unfit for human habitation. The order to vacate
remains in place. This dwelling shall remain unoccupied.
Recall that on October 22,2016, in accordance with M.G.L..c.I 11, sec. 127A and 127B, 105 CMR
400.000: State.Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.000:
State Sanitary Code, Chapter II: Minimum Standards of Fitness for Human Habitation,Thomas McKean ,
RS, CHO, Director of Public Health for the Town of Barnstable,conducted an inspection of the dwelling
located at 133 Beth Lane,Hyannis Massachusetts, accompanied by Police Sergeant Mark Butler on
Saturday October 22,2016 at 7:35 p.m.'after receiving a request for an inspection that evening from the
Barnstable Police Department. Based on the results of that.inspection,the Barnstable Health Division
determined that the dwelling was unfit for human habitation and all occupants were ordered to vacate the
dwelling.
If any person refuses to leave a dwelling or portion thereof,which was ordered vacated she may be
forcibly removed by the local Board of Health(Massachusetts General-Laws C. 127B), or by local police
authorities at request of the Board of Health.
Furthermore, anyone who fails to comply with any order`of the Board of Health may be subject to fines
up to $500. Each day's failure to comply with an order shall constitute a separate violation.
Note: This is an important le al document. It may affect your rights.
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PER ORDER OF THE BO RD OF HEALTH
Thomas A. McKean,R.S.., .O. ,
Director of Public Health
Town of Barnstable
Cc: Bill Rex,Hyannis Fire Department
Q:Order Letters/Housing/Condemnation/133 Beth Lane Reinpection 2017.docx
F' FIKE Town of Barnstable
��- Regulatory Services
wms!rABLE. »
"39- s,,r Public Health Division
tED NIA'
Thomas McKean, Director
200 Main.Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
March 29, 2017 .
Mr. and Ms.John and Sandra Hibbard
4 Terrace PI
Roxbury,MA 02120
RESULTS OF.RE-INSPECTION AT 133 BETH LANE,HYANNIS
On March 29,2017,the dwelling owned by you located at 133 Beth Lane Hyannis Massachusetts was re-
inspected for the third time by Thomas McKean,R.S.,Health Agent for the Town of Barnstable and
William Rex,Fire Inspector for the Hyannis Fire District. The following violations were corrected: '
410.482: Smoke detectors were not operational in basement-Corrected; a licensed electrician
was recently hired and new smoke detectors were installed.
410: 500: Broken front storm door;no window pane provided in storm door- Corrected.
410.602 (B): Excessive mold and multiple spider webs were previously observed on ceiling
inside the multiple debris filled closet located in living room-Corrected.
410:602 (B): Strong foul odors were previously detected in second bedroom to right(old stained
carpeting remains on floor where the dead cat was observed)and strong odors detected in last
bedroom at right-Corrected; the carpeting was removed from the bedroom on March 29,
2017 and was replaced with a newer carpet.
410.602(B): Feces were previously observed on the floor in basement where there were multiple
r cats- Corrected; the feces was removed.
410.500: Window pane was not provided in basement window; cats entering and exiting through
' the opening adjacent to air conditioner—Corrected; the air conditioner was removed and the
window pane was replaced.
410.500: Multiple areas of rotted wood observed at exterior along bottom of windows—
Corrected; new wood pieces were installed in multiple areas.
Q:Order Letters/Condemnation/133 Beth Lane Reinpection 2017.docx
410.452: No handrail provided at left side of front door stoop-Corrected.
410.452: The right hand rail at the front door stop was very loose and rusted at bottom-
Corrected.
410.351: Electrical cover plates were not provided at multiple light switches and outlets-
OTE: These were intentional) removed during painting of the walls; okay).
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410.450: Two rooms were observed in the basement that do not provide adequate second means
of egress—(These basement rooms are not to be used as bedrooms per Chief Building
Inspector Jeffrey Lauzon.).
Based upon these findings,this is no longer deemed unfit for human habitation.
The order to vacate is lifted and this dwelling-may be re-occupied.
Thomas A.McKean,R.S.,C. .
Director of Public Health
Town of Barnstable
Cc: Bill Rex,Hyannis Fire Department
Q:Order Letters/Condemnation/133 Beth Lane Reinpection 2017.d6cx
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The Commonwealth of Massachusetts
Attorney Paul T.Arnold,Jr. (508)760-02001894-3900
BARNSTABLE SS,
To Health Inspector Town McKeon
c/o Health Division
200 Main Street
Hyannis, MA
— greeting
You are hereby commanded, in the name of the Commonwealth of Massachusetts, to appear before the
JUVENILE Court Route 6A, Main Street
holden at Barnstable, MA within and for the county of BARNSTABLE
on the 31st day of MARCH,2017 at
9:00 o'clock in the FORE noon, and from day to day thereafter, until the action
hereinafter named is heard by said Court, to give evidence of.what you know relating to an action
of 'CARE PROTECTION Then and there to be heard and tried between
COMMONWEALTH,DEPARTMENT OF CHILDRENAND FAMILIES Plaintiff, and
IN RE: Rivera Defendant, and
Docket No. ,16CP001 SBA
you are further required to bring with you report/documents of your concerns/violations Of
property address at 133 Beth Lane,Hyannis owned by Louise Hibbard and Juan Rivera
whose children are in the temporary-custody o DCF
Hereof fail not, as you will answer your default under the pains and penalties in the law in that
behalf made and provided. _
Dated at Brockton the ' 28tIZ day of March
A.D.2017
I
otary Public, My"Commission expires on
JANINE L. SMITH
Notary Public.
COMMONWEALTH Of MASSACHUSETTS
My Commission Expires
UI) March 9, 2M
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oFIKE� Town of Barnstable
Regulatory Services
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MASS. a
lEDf/0�� Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
October 24,2016
Mr. and Ms. John and Sandra Hibbard n
4 Terrace Pl
Roxbury, MA 02120
DWELLING UNFIT FOR HUMAN HABITATION AND ORDER TO VACATE
In accordance with M.G.L. c.I 11, sec. 127Aand 127B, 105 CMR 400.000: State Sanitary Code, Chapter
I: General Administrative Procedures and 105 CMR 410.000: State Sanitary Code,Chapter H: Minimum
Standards of Fitness for Human Habitation,Thomas McKean RS, CHO, Director of Public Health for the,
Town of Barnstable, conducted an inspection of the dwelling located at,133 Beth Lane,Hyannis
Massachusetts, accompanied by Police Sergeant Mark Butler on Saturday October 22,2016 at 7:35 p.m.
after receiving a request for an inspection that evening from the Barnstable Police Department.
Based on the results of that inspection,the Barnstable Health Division finds that the dwelling is unfit for
human habitation. Pursuant to M.G.L. c. 127B'and 105 CMR 410.831 (D),the Health Division further
finds that the conditions within the dwelling are such that the danger to the life or health of the occupants
of the subject dwelling is so immediate that no delay may be permitted in'making this finding. Conditions
' found within the dwelling,which give rise to the emergency finding of unfitness include:
410.602(A): Multiple bags of garbage, rubbish, and filth piled outdoors on the ground adjacent
to garage, inside the garage, and on the ground adjacent to the fence.
410.200:. Heating system thermostat set at maximum setting(80 degrees)Fahrenheit but the heat
did not turn on. Internal.temperature remained at 60 degrees according to thermostat.
410. 450: Means of Elzress and 410. 451: Ellress Obstruction: Rear slider door blocked by a
large wooden door and piles of debris.
410.602 (B): Rubbish, boxes, old clothing, debris and filth piled indoors on top of beds, on
floors of bedrooms and piled on the floor within the finished basement.
410.602 (B): Dead cat observed beneath bed adjacent to paper trash bag, papers, bottles, clothing
and other debris on floor within first right bedroom.
Page I 1
410.602 (B1: Strong foul odors detected in second bedroom to right(inside bedroom containing a,
bunk bed).
410.602 (B): Master bedroom at left end of hallway contained large piles of clothing, boxes, and
other debris on top of bed.
410.602 (B): Excessive mold and multiple spider webs observed on ceiling inside.the multiple
debris filled closet located in living room. ,
410.351: No covers provided over the rusted baseboard heating system within kitchen. �.
410. 500: Broken/missing window pane in back right bedroom. „
410. 500: Broken slider-glass window pane in kitchen. -
410. 500: 'Severely bent front storm door; unable to close.
410 351: No cold water and hot water faucet handles provided.at kitchen sink.
Based upon these findings any and all occupants are hereby ordered to vacate and the landlord/owner is
ordered to secure the subject dwelling within 48 hours of receipt of this order. If any person refuses to
leave a dwelling or portion thereof,which was ordered vacated she may be forcibly removed by the local
Board of Health(Massachusetts General Laws C. 12713), or by local police authorities at request of the
Board of Health.
Furthermore, anyone who fails to comply with any order of the Board of Health may be subject to fines
up to $500. Each day's failure to comply with an order shall constitute a separate violation.
Once vacated.this unit may not be occupied without the written approval of the Board of Health.
Note: This is an important legal document. It may affect.your rights:
PER ORDER OF THE BOARD OF HEALTH
cKean,R.
Director of Public Health
Town of Barnstable
r ,
Page 2
Certified Mail:7015 1730 0001 4990 3073
�1HE Tp�
o Town of Barnstable
IARN$PABM Regulatory Services
Fa��
Richard Scali, Director
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
November 27, 2017
Mr. and Ms. John and Sandra Hibbard
4 Terrace P1
Roxbury,MA 02120
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II —MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 133 Beth Lane Hyannis, MA, was inspected on
November 24, 2017 by Timothy B. O'Connell, R.S., Health Inspector for the Town of
Barnstable. This inspection was conducted in response to a complaint filed with the
Town of Barnstable Public Health Division.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements
Observed holes, chronic dampness and mold like substance on the ceilings within the
kitchen area and within a bedroom area. This damage appears to be caused by a past
leaking roof. Although, during said inspection the inspector did not observe ceiling
leaking during very heavy rains.
You are directed to correct the violations listed above within (30) days
of your receipt of this notice by repairing ceiling. You are directed to correct the .
violations listed above within (7) days of your receipt of this notice by removing all
mold likes substances on ceilings and sources of chronic dampness.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten(10) days after the date the order is served. However, said
violations must be corrected within twenty four hours regardless of any request for a
hearing.Non-compliance will result in a fine of$100.00 per violation. Each day's failure
to comply with an order shall constitute a separate violation. Should you have any
QAOrder lettersWousing-Motel Violations\133 beth 11-27-17.doc133 beth In
questions regarding the above violations, please contact the Town Health Division and
ask to speak with the inspector who performed the inspection.
PER ORDER OF THE BOARD OF HEALTH
G
omas A. McKean, , CHO
Director of Public Health
Town of Barnstable
Cc: Janenne Gardiner
i
QAOrder letters\Housing-Motel Violations\133 beth 11-27-17.doc133 beth In
TOWN OF BARNSTAB.LE, '
Health Division 200.Main.Street- Hyannis, MA 02601
vAXData:
9, i63s• Number of pages including.cover sheet.
" PIED µpi L.
T0: FROM:
Town ofBamstable
Health Division'
Phone: Phone: 508-862-4644 °
71� — 36$t Fax hone: 508-790-6304
Fax phone: p
CC:
REMARKS: ❑ Urgent ❑ Tor your ❑ Reply ASAP ❑ Please comment
review
Certified Mail#7014 1200 0001 0358 4275
�'IKE F,
Town of Barnstable
BA"STABLE
•4,A MAS& Regulatory Services
r�ON`0�A Ricard Scali, Director
Public Health Division
Thomas McKean, Director
200 Ma-in Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
August 31, 2016
Sandra Hibbard
133 Beth Lane s Ida,S0 .
Hyannis, MA 02601 { Q>>
NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE CODE
The property owned by you.located at 133 Beth Lane Hyannis, MA was inspected on
August 30,`2016 by Town of Barnstable Health Inspector Timothy B O'Connell, R.S.,
because of a-complaint.
The following violation of the Town of Barnstable Board Code was observed:
§ 353-l'Responsibilities of, Owners and Occupants: Large amount of garbage and
rubbish located within a dumpster within the driveway of said residence: Trash was
spilling out and dumpster was without a cover.
You are directed to remove the garbage and*rubbish from this property and dispose
of it properly within 7 days of your receipt of this notice.
You may request a hearing'before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order-is served.
Failure to comply with an order.will result in a fine of$100.00. .Each day's failure to comply
with an order shall constitute a separate violation.
PER ORDER OF T BOARD OF HEALTH+ '
T cKean, CHO, RS
Director of Public Health
Town of Barnstable
Q:\Order letters\Refuse\99 walton.doc
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Certified Mail#7014 1200 0001 0358 4275
�. Town of Barnstable'
BARNSTABLB. +
;q. Regulatory Services
t6 ��
prF0N1P�A Ricard Scali, Director
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
August 31,2016
Sandra Hibbard
133 Beth Lane
Hyannis, MA 02601 ` ..
NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE CODE ,
The property owned by you located at 1133 Beth Lane Hyannis, MA was inspected on
August 30, 2016 by Town of Barnstable Health Inspector Timothy B O'Connell, R.S.,
because of a complaint.
The following violation of the Town of Barnstable Board Code was observed:
353-1 Responsibilities of Owners and Occupants: Large amount of garbage and
rubbish located within a dumpster within the driveway of said residence. Trash was
spilling out and dumpster was without�a cover.
You are directed to remove the garbage and rubbish from this property'and dispose
of it properly within 7 days of your receipt of this notice:
You may request a hearing before the Board'of Health if written petition requesting same
is received within ten (10) days after the date the'order is served.
Failure to comply with an order will result in a fine of$100.00. Each day's failure to comply
with an,order shall constitute a separate violation.
PER ORDER OF T BOARD'OF HEALTH
T cKean, CHO, RS
Director of Public Health
Town of Barnstable
QAOrder letters\Refuse\99 walton.doc
' ~ Health Master Detail Page .1 of,1
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Logged In As: TOWN\oconnelt Health McaSter Detail Wednesday,August 31 2016.
Application Center Parcel Lookup Selection Items
Parcel Septic Perc Well Fuel Tank
Parcel: 272-167 Location: 133 BETH LANE, Hyannis Owner: HIBBARD,JOHN &SANDRA
Business name: Business phone:
Rental property: Deed restricted: ❑, Number of bedrooms
Contaminant released: ❑ Fuel storage tank permit: ❑
vSave Parcel Changes'
`Return to Lookup�I
Parcel Info Parcel ID: 272-167 Developer lot:LOT 40
Location: 133 BETH LANE Primary frontage: 125
c Secondary road: Secondary frontage:
Village:Hyannis Fire district:HYANNIS
Town sewer exists at this address: NO Road index:0119
Asbuilt Septic Scan`. 272167_1_ Interactive map
Town zone of contribution:GP (Groun Ater Protection Overlay District) state zone of contribution:IN
Owner Info Owner: HIBBARD, JOHN &SANDRA Co-owner:%HIBBARD, SANDRA
Streeti:4 TERRACE PL Street2:
city:ROXBURY - .. state:MA zip: 02120 Country:
Deed date:.7/30/1999 Deed reference:12444/15.7
Land Info Acres: 0.35 use: Single Fain MDL-01 4 zoning:RC-.1 Neighborhood: 0105
Topography: Road:
Utilities: . Location:
Construction Info l5uildinq NdYear Buil Gros's ArealLivinq Are Bedrooms Bathrooms
1 11980 13818 11396 13 Bedroom 2 Full-0 Half
Buildings,value:$110,700.00 Extra features? $48,300.00 Land value: $108,700.00
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http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=272167 8/31/2016
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Citizen Web Request Page 1 of 2
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LoggedIn 'Citizen Request Management •.��.�r��3Y;A�9ustz�2°16
TOWN\ - .
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Route to Users Search Requests Create Reauests
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Request Information
Request ID: 57152 Created: 8/24/2016 3:14:26 PM
Status: Assigned To Staff Assigned To: O'Connell,Timothy
Health Office
:
Anonymous Chapter 54-5 Rubbish and No Request Category: Garbage edit
Routine work: No -Estimate: No edit
Date scheduled: y edit
Estimated 9/8/2016 Change Estimated Aug September 2016 Oct
Completion Completion Date:
Date: ''. Sun Mon Tue Wed Thu Fri Sat
28 29 30 31 1 2 3
4 5 6 7 8 9 10
11 12 13 14 15 16 17
18 19 20 21 22 23 24
25 26 27 28 29 30 1
Created By: Wadlington, Ellen. Priority: Medium edit
Health Office
Citation Numbers: edit
s _ ,
Requestor Information
Requestor
Hyannis, Ma 02601
i
Request Parcel Map: 272 1 Block:, IL67 Lot: 1000 -
Per person,this is a Number — - --
"known drug house". Has
dumpster in drive way that is Parcel Lookup
overflowing.
Email;
Edit Requestor Information
Track Request Progress
+Request Work History: Internal Note History:
System entry on 8/24/2016 3:14:26 PM:
Assigned to O'Connell,Timothy
{ s
http://issgl2/internalwrs/WRequest.aspx`?ID=57d152 8/26/2016
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TOWN OF BARNSTABLE
'A
LOCATION �Ia — SEWAGE #
VILLAGE kk U QU'-,f\V S CWSS -ASSESSOR'S MAP & LOT.Z7,9 &,
INSTALLER'S NAME&PHONE NO.
SEPTICF TANK CAPACITY J.CDC ® q c"-�
LEACHING FACILITY: (type) toy- (size)
NO.OF BEDROOMS `
BUILDER OR OWNERS
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility C;2 0 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) A) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachi�}�j facility) Feet
Furnished by jl —
.�, .
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i �
;3;.. COMMONWEALTH OF'.:NI,ASSACHUSETTS
7.
t �' I: -FCI..11% 4- FFIC'E OF "Eti�'IRO\�tEtiTfli, AFF.U16-
I j I EPARTM NT OF EwiRONME, dTAL PROTECTION
0.. ,,,\T�R s STFtEET.,,I3 . (I 05T0N \IA '21QK 16171 292.5500
..
�`'II,LIAM F.WELD ;RUDY CORE
Secretary
Governor
:':RGEO PAUL CELLUCCT Dr1N1D B. STRUHS
Lt. Governor '
SUBSURFACE SEWAGE DISPOSAL SYSTEM IN19PECTIONTORM `3
PART
Lo an
• CfRTfFICATl01� ��'
r
Property Address: 13� t,a�� �ta^JIY�I�.A S .r mos .address of Oa rBer: P ' RfeEIVE®
Date of Inspection: V;Ilstern
,: 0i diterenII .; AUG �1 A
'game of Inspector: 1�yNL�1 1 't 19C'�8
I am a DEP inspector pursuant fo'.Sectilon 15.3s0 of Title 5 1310 CMIR 15:000) TOWN OEBARNST �?r
Company Name: f HEALTHDEPi��
5cailingAddress: in 4 95,Vo76�t1
Telephone Number:
®t 6
CERTIFICATION STATEMENT
1 certify that I have personaliy,inspected the se`�aee disposal system at this address and that the information reponed beloN'v Is true, accurate
and complete as of the time of inspection. .The :nspectlon tiva, penormed`based on-my training and experience in the proper function and.
maintenance ol`on-site sewage disposal systems. The system
Passes
NepdG FurtnPf hValUl{ICd'l,;V In?inr.al APDrovine ALJMEYNtV
Fails
inspector's Signature: }` 'Date:
The System Inspector shall submit a copy of this Inspection repun to the Approving Authority within thirty(30)days of completing this "
inspection. If the system`is'a shared system or has a design flow of 10,060 gpd or greater;the inspector and the systern owner shall submit.,
the report to the appropriate regional'office of the Department of Environmental Protection .The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY. Check A,. B, C,-or D: {
Al/SYJ
M PASSES;
have not found any information which indicates that the system.violates any of the failure Friteria as defined in 310 CkAR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS-
GJ SYSTEM CONDITIONALLY PASSES:
One or more system components as described+n t onditional Pass section need to be replaced,,or repaired. The system, upon
completion of the replacement or-repair, as oved by the Board of Health, will pass,
ndicate yes,no, or not determined (Y. N o ': Describe basis of determination in all instances. If"not determined", explain ,why not.
The septic tank is , uniess the owner or operator has provided the system inspector with a copy af:a Certificate of
/ Compliance tat ed) indicating that the tank was installed within twenty(20) years prior to the'date of the inspection; or_*
the:septic It whether or not metal,`Is cracked,'structuraHy unsound, shows substantial inflltratson or exfiltration, or tank
failure Imminent. The'sysiem,will pass Inspection if the existing septic tank-is,replaced with a coninrming septic tan$(
as proved by the Board of Heal(h. .
• r,
vtroviead 04 7S/97) Page 1 a '10
. Viv Pnntea On�Recvcleo NOR, ..
SUBSURFACE 5EWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART 1 .
CERTIFICATION (continued)
Property Address: TL �
Owner: %,XCAv �..t9.rh p'rDS
Date of Inspection: v' clil,,�
BJ SYSTEM CONDITIONALLY PASSES (continued: ,
Sewage backup or breakout or nigh sttmc water level ob<cr.e d'tn the distribttti \ 1� clue to broken or, rtt��trt C:t:
pipets) or due to a broken, settled or uneven;distribution box. The sv will pass inspemon ,+ wilh approval o: tile
Board of Health). Describe observauons:
broken otpe(s) are replaced,
obstruction'ts removed,
distribution box is level r replaced "
The system required pumping re than four limes'a year. oue to hroken or obstructed pipets). The system will t:itss
_
inspection if(with appro of the Board of Health); F
en pipets) are replaced
obstruction is removed'"
t t
r
Cj FURTHER EV LUATION IS REQUIRED BY THE BOARD OF HEALTH-
Condition
Conditions exist which require further evaluation by the Board of Health in order to determine ti the'system i5 failing (o protect the
public health, safety and the environment,
1) SYSTEM Will PASS UNLESS BOARD OF-HEALTH DETERMINES THAT T STEM IS NOT FUNCTIONING IN A MANNER
1t'}i1(N tt'ttt PtiflTaT iHF Pfaitt� Nr:.tTt� .\7 SAF(1''i s\
Cesspool or privy is within 50 ieet of a surface wa , ;
_ Cesspool or privy is within 50 feet of a border" vegetated wetland or a salt marsh.
2) SYSTEM WILL: FAIL UNLESS'THE BOARD OF LTH (AND'PUBLiC.WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MAN R THAT PROTECTS THE PUBLIC.HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has ra septic to and soil'absor"ption system (SAS)and the SAS is within 100 feet to a surface water supply or
tributary to a surface wa r supply.
The system has a septi tank and soil absorption system anal the SAS is within a Zone I of a public water supply well.
_ The system has a se tc tank and soil absorption systemand`the SAS is within 50 feet of a private water supply well.
J. The system has a ptic tank and soil,absorption system and the SAS is,less than 100 feet but 50 feet or more from a',
private water s ly well, unless a well water analysis for•coliform bacteria and volatile organic compounds indicates that
the well is fre from pollution from that facility and the presence,.ofammonia nitrogen and nitrate nitrogen is equal to or
less than 5 m. Method used to determine distance (approximation not valid).
3) OTHER r ,
• r:
1(reviaed 04/25/97) P69w 2 of: 10
SUSSURFACE SEWAGE DISPOSAL SYS11M.INSP[CT10` FLrR'.t
PART A
CERTIFICATION (continued) ,
Propertv Address: t 33 'Bt}I, ����•
Owner:
Date of Inspection: Q jC 1 LQ1&
v ` �.
D) SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I ha\e determined that the system violates one or more of the followmc failure criteria as'defined in 310 CMR 15.303 The basis
for this determination is identified below, The Board of Healih should be contacted to mine \%nat will he necessary to correct
,he failure..
1 f•. Nn
Backup of sewage into facility or system;component due t overloaded or clogged SAS or cesspool.
Discharee or ponding of effluent tc�;ne surface of Sround or surface waters,due to an overloaded or clogged SAS or
cesspool.
y
t Static liquid level'in the distribution b above outlet invert due fu an overloaded or clogged SAS or cesspool. t, .
�. Liquid depth•in cesspool is less an 6" below inven or available volume is less than 1;2 day slow.
Required pumping more an 4 times in the last year NOT due to clogged or obstructed pioesi:
Number of times pum
any portion of th Soil Absorption System, cesspool.or privy is beioWthe high groundwater elevation. "
-\rn• portio+i a cesspool or privy is within 100 feet of a surface water supply or aibutary to a surface %vater supply.
-:nY po n of a cesspool ar rr.•,•N �s ,t.,in, a•..on c of a Nh e Il '
Any onion of a cesspool or privy is within 50 feet'of a private water supply well.
y portion of a Cesspool or privy is less than 100 fr..et but greater than 50"fPct from a private slater supply wnh nc;
acceptable,water quality analysis. If the well,has been analvzed to be acceptable, attach copy of well water .-nah'sts for
cohform bacteria, volatile organic compounds,''ammonia nitrogen end nitrate nitrogen.
Q LARGE SYSTEM FAILS: ,
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply,to large systems in addition to the cite ' above: '
The system serves a facility.with a design flow_ of 10,000 or greater (Large'System)'and the system is a significant threat to
public health and safety and the environment becaus ne or more'of the following conditions exist:
Yes " No
" the system is within 400 f of a surface drinking water supplyy, -
the system is withi 0 feevof a tributary to a surface drinking water supply, a
the system is I ted in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPAI oralmapped Zone II of a `
public ware supply well) ,
i
The owner or operator of v such system shal! bring the system and facility into full compliance with the groundwater treatment program
requirements of 31.1 C 5.00.and 6.00,,Please consult fhe local regional office of the Department for further information.
., t(raviaad 04/7S/91) , Pago 3 of 10 ,
SUB Sl.iitFACE SEIVAGEDISPOSAI 5YSIIS1 INSPECTION FORM
PART,B.
"CHECKLIST, ,
Property Address: 113 13eiii,,, Lc, '. ++
Owner: Q&veyptros
Date of Inspec:lon- Q +�[ a 40
Check if the iollowing have been done: You nwst''Indreate either "Yes" or "No as to each of the fnllowmG
Yes No
Pumping information was provided by ihe.owner, occupant, or'Board o(Heaith:
None of the system_ components have been pumped for at least'two weeks and the system has been receiving normal,
flow rates during that period. Large volumes of water have nor been introduced Into the system recently or
as part of this inspection."
ks built plans have been obtained and examined. Note li they are not available'with N/A.
` The facility or dwelling was inspected,for signs of sewage back-up.
The system does not receive nbn-sanitary or industrial waste ilow.
sw
The.site was inspected for signs of breakout:
All system components; excluding the Soil Absorption System, have been located on the site.
<
WC�'(•UVscovE►Ctk1�G6' ✓�E�1
av1Gi't�!tt C�t�t�ov�3.C�
e.��.
udltieS or tee , mdterldi ul cuilstrucl.unr dimensions,.uepth iji :iituid, depth of sludge,dep Ot Scu,
The size and location oi'the Soil Absorption Svstem on the site has been'determined based on:
?he facility owner land occupants, if different from owners were provided with information on the proper maintenance of
Sub-Surface Disposal System. . r
Existing information.U. Plan at S.O:N. -
Determined i6 the field (if any of the'failure criteria,related to Part C:is at issue, approximation of distance Is
unacceptable) 115.302(3)(b)j
t
11(reviaod 04/25/97) Page 4 of 10,
SLJBS(WACE SEWAGE DISf OSAL SYSTEM INSPECHO s FORM
PART C
SYSTEM INFORMATION
Property Address: 13 e--Vvs, + wi°
Owner: "11 gp^f rc s
Date of Inspection:
FLOW CONDITION'S
RESIDENTIAL:
Design flow: no g,p.d.ibedtoom for S.A,S.,
Number of bedrooms: %T J
'umber of current residents:
Garbage grinder ryes or no):iub t
Laundry connected to systgm. (yes or not: t/41?s '
Sep .;at use(yes or no): No Ny� Q S?ex�o ,.(S
Water meter readings, if ava;cable alast hwo t?) year u>age ! pdr ✓ 7.0� L� [ �°^�
Sump Pump Ives or no):
Last date of occupancy: C,ryi"W%i
CUMMERCIAIJINDUSTRIAI:
Type 0 establishment:
Design flow: callonsiday
Grease trap present: (yes or not M
Industrial Waste Holding Tank present'. (yes or nor
Nun-santtan waste discharged to the Title 5 syst : eyes or not
Water meter readings, if available:
OTHER: (Describe)
Last date of occuoancy:
GENERAL INFORMATION
_PUMPING RECORDS and ource of inform lion:
System pumped as part of inspection: (yes or no)_,_
If yes.volume pumped: gallons
Reason for pumping:
TYPE Oj 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)
I/A Technology etc. Copy of up to date contract?
Other - - --
J APPROXIMATE'AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or not
� (ravasod 04/75/97) Pay 5 of 10
i • ,
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C`
SYSTEM INFORMATION Iconiinued)
Property Address:
Owner: �,k^f MIS Q
1 i
Date of Inspection: Q ( 8•� •'
BUILDING SEWER: G
;Locate on site plan) ,
F .
Depth below grade:
4017%tatenal of construction: _ •ra,t iron :G'PV _ oilier tezpla�N
Distance from private water supply v:el r suction line
Diameter
Comments: (condition of joints niing,evidence of leakage, etc.)
SEPTIC TANK:-
;locate on site plan)
Depth below grader(�
material of construction. _concrete '1wal Fiberglass PolvelhvJene _oihertexplain) s
if tank is +metal, list age_ Is age cor.r,rtned by Ceniricate of Compliance tYes/NW.
Dimensions: 10Ob �` �l
S)udee depth14df
T ( c ( �" t 97
s�4�c"�S..�6Sryt UT Ov" �.\1�y�vr - \�
Scum thickness: a _ u
Distance from top of scum to top of outlet tee or baffle: t1D
`Distance from bottom of scum to bottom of outlet or baffler
How dimensions were determined:
`Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in feiation t i outle nvert, structural
-Iriintegrity, evidence of leakage, etc.)
ettA- —noes tripleag,
GREASE TRAP:
(locate on site plan)
Depth below grade: =s t
Material of construction: ._concrete _metal•_Fibergl _Polyethylene,�'other(explain)
Dimensions
Scum thickness
:-
"Distance from top of scum to top of,o t tee or baffle: _
Distance from bottom of scum to b om of outlet tee or baffler
Date of last pumping:
Comments:
(recommendation for p ping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of akage, etc.)
(revised 04/25/97) sago 9 of 10
SL 8SURFACE SkWACE:DISPOSAL SYSTEPO INSPECTION FORM
PART C
SYSTEM INFORMATION icontiniuedl
?ropert% Address: ` 15 3
O»ner:
Date of Inspection:
TIGHT OR HOLDING TANK: Tank must lie pumni•d prior to.Pr at time, crt,msoeclioni
;Coat:' on s!te plant
Depth below srade:
�tatena! of construction: _concrete �-eial'_Fibercla Pcllvethylene_ntiterietipiatnl
Dimensions:
irapaCity: __ gallons ti
pesign ilow: gaHonsl
�.iarm level: hlarm working order `o
Date of previous pumping:
'Comments: y
contiiiion of inlet tee. ^dition of alarm and float s�ti rcnes, eic.f
DISTRIBUTION BOX:
,lobate on site plant '
Depth of liquid level above outlet invert:' ��1✓��
Comments:
thate if level and distribution is equal, evidence of soljos ca.rrvover e idenc of leakage into or out of box,etc.: .
-tom Mai �, as 6elzeL a.nd-'t l4 h f 6 4 h o'-V ear t.-W
r
PUMP CHAMBER:
(locate.on site plan)
Pumps In working order: lYes or No)
Alarms in working order(Yes or No) =
Comments:
(note condirion'of pump chamber, Cori ditic umps and appurtenances, etc.)
ftrev%sod 04/15/97) Pogo 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSIEM INSPEC.TIO`: FOR i
P:aRT C
SYSTE,si I %FOR`ATION (continueuF
Property Acrecs:
0 3 `13e 1--car¢
Owner: (7y�M�
Date of Inspection: Me
SOIL ABSORPTION SYSTEM (SAS);v
locate on sae plan, if possible: excavation not required. Inq;iray he.approximateo."I)v non intrusive methoasi
(: not determined to be present, explain.
Tvpe
leaching pits, number:
leaching chambers, number:
ieaching galleries, number:
;eaching trenches, number,lenath:
leaching fields, number, dimensions:
overflow cesspool, number:
.-ilternative system: "
Name of Technotogy:l
Comments:
tnnie cot d I n of soil, sighs of hydraulic failure, level of ponding, cq�dition of vege.utior. c.)
'rV1 '_i 4 t �- t (1.� _4 W
7.
CESSPOOLS:
ilocate on site plant
Number and configuration:
Depth-top of liquid to inlet Invert:
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool: r
Materials of construction:
Indication of groundwater,
inflow (cesspool mus' pumped as part of inspection)
Comments:
(note condition o soil, signs of hydraulic failure; level o ponding, condition of vegetation, etc.) -
PRIVY:
i locate on site plan) s. ,
,`laterals of construction: Dimensions:
Death of solids:
:Comments:
note condition of soli, signs X--draulicfailure, level of pundmg, condition of vegetation, etc.)
• is
1(revase4 04/23/97) Paya a of 10
SLBSLRF.ACE SO AGE.E)ISPOSAL S'IS1EM jr%5PECTION FOR1%
PART.0
SYSTE.M I1,FORMATION,(codtinued)
Property Address:
Owner: L'paft-off
Cate Ut Impec;iun:
SKETCH OF SEWAGE E)ISPOSAL SYSTEM:
•nclude ties to at feast two Vermancnt rcterences :zindmarla or oencnmarK� ,
Cate ail %.ells �. tnin 10t1' iLcu-mv wivre pruo:�c -voter suppivfCmCS into houst•i'
e
t
l(xevtawd' 04!25/97) Page 0 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEI'I INSPECnON FORM
PARS' C
SYSTEM L TORMATION (continued)
Property AddreaN:
Owner:
Date of Inspection:
Depth to Groundwa;cr WdFeet , ..
Please indicate all the methods,used to determine High Groundwater Elevation-,
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local,conditions
Check with local Board of health
Check FEMA Maps
Check pumping records.
Check local excavators:.installers
Use USGS Data -
Describe in your own words how•you established the Hit" Groundxa E)e a:te Q%Iust tr completed)
ke ,at
ir
b6 911,14 oq 4ea
9 �
t {Miwd o1173i'!71 � ,P�10 d 10: � .
o - S
L0"CAT�10N /3-2) SEWAC`E PERMIT NO.
VILLAGE
P F A
I N S T A LLER'S NAME & ADDRESS
7 C�h ru /,),I A�'i��
R U I D E R OR OwN ERA
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
J y `
r r
f
NO
% INQ
�i�
r ,
No. ........ . � FR$...... ..........:.........
THE COMMONWEALTH OF•MASSACHUSETTS
BOARD. F HEALTH
..........�' ..-.. o f ..... Q; .�
Apli iratioo -for Uiipoott1 Works Tatuitrurtioo Prrutit
Application is hereby'made for a Permit to Construct (V<or Repair ( ) an Individual Sewage Disposal
System at: �
.y, YJ - --r!•---. •o r s r l 1 1�.riLr�� t vVOT /1�'��3
'---...-------7-- --------------- - --f!�----- = ------ ----- --------. I.----•--........------......- --� ----
------------ -- -
wn Address
. •. •----- - v rN-----•-•r -------------------------•----••--
Installer Address /-��
UType of Building Size Lot_._ -__________---------Sq. feet
Dwelling—No. of Bedrooms...........................................Expansion:Attic ( ) Garbage Grinder ( )
Other-Type of Building ._5.qD-_-_----- No. of persons____________________________ Showers O — Cafeteria ( )
Q, Other fixtures ------------------------------------------------------
Design Flow............................................gallons per person pe ay. Total daily flow_---------��®--___---.-..--__ allons.
WSeptic Tank—Liquid capacity I��gallons Length....... ___ Width_.__`j._----_- Diameter__-__-*�.___ Depth.4. _-
x Disposal Trench—No. .................... Width
�-- G_ _..--. Total Length---------
...__.. Total leaching area........_----....sq. ft.
Seepage Pit No----------L-----____ iameter.../-------------- Depth below inlet------- Total leaching area._.___-_sq. ft.
z Other Distribution box (c� Dosin tank )
~" Percolation Test-Results Performed by. ... Date---_--------------------
Test Pit No. 1 Z minutes per inch Depth of Test it-------------------- Depth to ground water-- ---
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground .water----------------------
----------- ----------- -- - ---- ....................................................................
O Description of Soil--------® I` •---"---- ------------------------ ........................................................
1
aw •---------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable..................:....:.......................................... -------
------------------------------------------------ .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig -- ---- A----
Date
Date
Application Approved BY & ------------------------------- ••--
Ry,pate
Application Disapproved for the following reasons:.............•---:..---•--------•-------•--•--•---------•---•-•-••••-•--•---.....---------=••-•------••---.•---
..........................................--•-----------------.----•--••-------•---•----•-•---------•---------.------.-.--•----••----------------------------------------•---------_.....-----•--.-••--
' ? Date
PermitNo.......................................................... Issued-----•.. --- --------------------------------
Date
•
04
No..- - ....... � Flm$ ......................
V cFJ THE COMMONWEALTH OF MASSACHUSETTS
BOARD` F HEALTH
............... .4_.....
. -.;Appli.ration -for Uiiipoottf Works Toni#rnr#ion Prrutit
Application is hereb made for a Permit to Construct V or Repair an Individual Sewage Disposal
PP. Y• ( ) P ( ) a P
System at
------------- ------ ---- S �+N� .. ....- ........ *1 1 °t -- - - ' " t
wn r ° Address
a -- `----- — - -- - . - .............. UW F_I _.I 7./'"�«----•-• --•----------------..._
Installer t Address
U Type of Building Size Lot..J...�Q Sq. feet
DwellingNo. of Bedrooms - -.-"---__�To. of persons
Expansion Attic Showers Garbage
eia
— P ( ) g ( )
aOther—T.ype of Building _ p O ( )
d Other fixtures -, = ---
W Design Flow............................. _gallons per person pe ay. Total daily flow.__------- �-______ ;��-,ga.l�.l•o-•ns.
WSeptic Tank—Liquid capacity -gallons Length_____- --- Width..._`�. ...._.. Diameter___--�._..._ Depth _�'•!""
x Disposal Trench—No'°___________________ Width.................... Total Length---------- Total leaching area--__--_---_r,-----sq. ft.
Seepage Pit No.__---____�-------_. Diameter___/.............. Depth below inlet--------- Total leaching are�i<ZS47__.___sq. ft.
Z Other Distribution box ( Dosin tank
'-' Percolation Test Results .Performed by. _______ _______ ?_ _. Date___.........__-._..______. ________._..
a minutes per inch Depth of Test it______________ Depth to a-- ............ ..... ground Ovate ---------------•--•----
Test Pit No. 1_._____�:...
(� Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground wd&r----------
_-------------
------------
D Description of Soil------- ----------`--�'�---- ------ � ^ `-..-- . a... ------- ----- ------ - ---------- -----------------
v --------------- --------- - --- --- -----1---`- -
W `'
UNature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------._.__--___.- -__...
•------------ ----------------- ------------------------------------------•--------
,, Agreement
The undersigned.agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board if health.r
t
Dat
Application Approved By...... ,'`--" - 'r j •--•---•-- ,•. date
Application Disapproved.,for the following reasons------------------•-----------------------------•-----------------•--------------------- -•-- ................
.. ----------•--•---•-•................----------------------------------------------•-- -----------------------------------------------------
Pate
PermitNo-------................................................. Issued----------------------------------.......................
Date''
THE COMMONWEALTH OF MASSACHUSETTS
s YL�
` BOARD OF H ALTH r
..:.. oF.;:°.. .............. 1 .....................................
Ter#if`irtt#e of Tomptitt re
RHIs I 0 CERTIFY, That theIndividual Selwage isposaj Is ( or Repaired ( )
r .
bY------- ---
t .. - - --' s 11localer - ---� -•-- ------• - --
IMFT h1 p4 _ _•
at.- T �t -
' --- +
has been installed in-accordance with the;provisions of : --
t e XI of amtary Co e s described in the
application for Disposal Works Construction Permit N .. : .- -_ .__ dated.... .. -7-----------------_----
THE ISSUANCE OF THIS CERTIFICATE SHALL yNOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM,,YtIILLP FUNCTION SATISFACTORY.
s
DATE.............. .........................................................------- Inspector --- ----------------------------• .....................................
r a'
f THE COMMONWEALTH OF MASSACHUSETTS
BOARD .'OF HEALTH
.... d.140.7. ..... OF ....:.:
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Permission i hereby granted......' .... ... ?
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to Constru ,�(( for'R air ) a ndividu Sewage Dis I ste I.
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as shown on the application for Disposal Works Construction Perm' . o r_. Dated-___ -----2P7_
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