Loading...
HomeMy WebLinkAbout0195 DUNN'S POND ROAD - Health 77� 1.-Q5'Dunn's Pond Road Hyannis P A = 270 006 r Certified Mail#7005 1160 0000 0191 0348 �P�oFwt t roy,o Town of Barnstable Regulatory Services It'i BARNS-rauLn,,+, 9 MASS. Thomas F. Geiler, Director 039. o�ArF0 MA'S ale Public Health Division e Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 29, 2008 Ellen Cordry Kathleen Tomasello 110 Buckskin Path -Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 195 Dunn's Pond Road Hyannis, was inspected on January 18, 2008 by Meredith Morgan, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.350 —Plumbing Connections. Kitchen sink faucet not affixed properly; bathtub not draining properly. 105 CMR 410.500— Owner's Responsibility to Maintain Structural Elements. Cracked front door. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by repairing kitchen sink faucet; by repairing bathtub drain; by repairing or'replacing cracked front door and ensuring it is sealed and weathertight. QAOrder letterMousing violations\Rental ordinance\195 Dunn's Pond Road.doc I t. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER R O THE PER OF HEALTH masORDE A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Meredith Morgan,Health Inspector Sherry Eddy, Tenant QAOrder letterMousing violations\Rental ordinance\195 Dunn's Pond Road.doc FORM30 Caw HOBBSBWARRENTM THE COMMONWEALTH OF MASSACHUSETTS ,v. BOARD OF HEALTH CI p I OWN W a D PARTMENT , A ESS (&� �M SVOye. �nEPHONE Address ��1,lJNS �pY� � ,_ Occupa t�ILY6 Floor Apartmen o. No.of Occupants No.of Habitable Rooms No.Sleeping Rooms No. dwelling orrooming units No. tones Name and address ress of owne E A) ahoe r MA 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: y Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: f' Hall Lighting: Hall Windows: HEATING Chimneys: Central 6�,A� ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safetv and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: r . ey raLyy 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 OY Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent.,Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION R RT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI F U Y ' INSPECTOR TITLE &afttZ4 en�n� A DATE TIME ` A.M. THE NEXT SCHEDULED REINSPECTION 725D 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 acid 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,7which prevents egress in case Iof 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). .(I) 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. x . (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. ` ! L t Ellen Carty Cordry 110 Buckskin Path Centerville, MA. 02632 • 508-778-4179 January 6, 2008 Mr. Thomas McKean, Director Public Health Division Town of Barnstable Regulatory Services 200 Main St. Hyannis, MA 02601 Mr. McKean, In response to your certified letter dated December 18, 2007 and received by me on December-27, 2007, regarding the property at 195 Dunn's Pond Road, please note the following corrective actions: 105CFR 410.200 • 12/17/07 I am notifed:by.my tenant of,a problem:with the heating system • 12/18/07 , I;.responds to mytenant;that:I ;have arranged the proble ta'be evaluated • 12/18/07z-:I-am ,informed:by my tenant�that she has:contacted the-Departrqgnt = of,Health 12/19/07 - an assessment and evaluation was conducted by HVAC ecialistx) Joey O'Hare and it was determined.that a new heating system is n ` ed to -© supply heat to all the rooms 12/20/07 - financing arranged for a replacement heating system • 12/31/01 - estimate for work finalized and work plan developed r1_0 • 01/02/08 - installation begun • 01/12/08 - estimated completion date 170-4 Certificate of Registration • 12/27/07 - I was first made aware, in your letter, of the requirement to register my rental property with the Department of Health. (Note: when I inquired, on January 4, 2008, as to the method for notifying rental property owners of this requirement,,.1 was informed by,.a,member of your staff that the requirement was publicized in the newspaper and on television several months ago and that local realtors had;been:notified at that time.. I;remain concerned thatahere.is adequate notification process, especially for rental property owners like me, who do not;use rental.agents..,An y.clarification_you could"provide regarding.the Department's,:notification method would•.be greatly;appreciated), o - 1 - Ellen Carty Cordry 110 Buckskin Path Centerville, MA. 02632 508-778-4179 12/28/07 —Application for Rental Registration completed and mailed to your address, along with a check for the required fee ($90.00). • 01/03/07 — I was informed by Health Inspector, Meredith Morgan, that my application and fee had not been received. • 01/04/07 — I personally submitted a copy of the application and a second check for the $90.00 fee at the Department of Health offices. I also received by mail a Notice of Violation of Town Ordinance or Regulation notifying me of the $100.00 fine and I sent a certified a letter to the District Court, First Barnstable Division, requesting a hearing to contest this matter. • 01/05/07 — the original application and check were returned to me by mail. The envelope containing the application and fee is stamped received by the Town of Barnstable on 01/04/07. 170-10 — Maintenance of smoke detectors and carbon monoxide alarms • 01/05/07 —the smoke detectors on the main level have been upgraded to hard- wired-models, with battery backup, and an identical unit has been installed in the crawl space (Note: the dwelling does net have a basement, as specified in your letter.) Thank you for your attention to my response. 'Sincerely, Ellen Carry Cordry -2 - .r W�r icy i y M f March 26, 2008 RE: Housing Violations at 195 Dunn's Pond Road, Hyannis Dear Sir or Madam: This memo is to state that on December 18, 2007, Donna Z. Miorandi, Health Inspector for the Town of Barnstable performed some temperature checks at the above listed dwelling. The findings were as follows: The temperature in the living room while standing in front of the heater was adequate. However, in the rear rooms that do not have heating vents the room temperature was at 59 degrees Fahrenheit. The minimum standard is 68 degrees for the daytime and 64 degrees for night time. It was also observed that there is no insulation in the attic or the basement. It is my belief that insulating this dwelling would help alleviate the problem. There are existing programs available to homeowners and tenants to evaluate these problems and assistance for payment of such energy conservation measures. Over the years this dwelling had only a seasonal use during the warmer months of the year and thereby the problem had not presented itself until it has turned into a year round occupancy. Thank you for your time and consideration in this matter. If there are any further questions please feel free to call my office at 508-862-4644. Sincerely, Donna Z. Miorandi, R.S. Health Inspector Town of Barnstable i r J Town of Barnstable Barnstable Regulatory Services DepartmenttCe BA"ST"LL M Public Health Division &639• m rFa" A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO March 26, 2008 RE: Housing Violations at 195 Dunn's Pond Road, Hyannis Dear Sir or Madam; This memo is to state that on December 18, 2007, Donna Z. Miorandi, Health Inspector for the Town of Barnstable performed temperature checks at the above- referenced property. The findings were as follows: The temperature in the living room while standing in front of the heater was adequate. However, the rear rooms that do not have heating vents were measured at 59° Fahrenheit. The minimum standard is 68' for the daytime (between 7AM and 11PM) and 64' for the night time(I 1:01PM to 6:59AM). It was also-observed that there is no insulation in the attic or basement. It is my belief that insulating this dwelling would help alleviate the problem. There are existing programs available to homeowners and tenants to.help evaluate the heating issues and provide assistance for payment of energy conservation measures. Over the years, this dwelling was only used seasonally during summer months, therefore the problem had not presented itself until the dwelling switched to year-round occupancy. Thank you for your time and consideration to this matter. If there are any further questions,please feel free to call my office at 508-862-4644. Sincerely; Donna Z. Miorandi, R.S. Health Inspector Town of Barnstable JA195 Dunn's Pond Road.doc McKean, Thomas From: McKean, Thomas Sent: Friday, February 01, 2008 9:49 AM To: Lomba, Lois Cc: Morgan, Meredith Subject: Ellen Carty Cordy- 195 Dunn's Pond Road- $100 Non-Criminal Ticket Citation This morning I talked to Tom Geiler about this- The Health Division requests the ticket recently issued to Ms. Cordy be voided or withdrawn. Ms. Cordy complied in early January by registering the rental unit. I am told that the date the ticket was mailed was within one day of us receiving her registration application and fee; hence the two pieces crossed apparently in the mail. 1 P�oFt"Elm,, Town of Barnstable ,AR,s,ABLE ; Regulatory Services 9c� 39 � Thomas F. Geiler, Director •eTFD NIA' A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 DATE: NUMBER OF PAGES TO FOLLOW: r TO• , /I F ro c lye PHONE: PHONE: (508)862-4644 e - r3� FAX P7CJ , FAX PHONE: (508)790-6304 cc: NOTES/COMMENTS: QAFax Form.doc Town of Barnstable �pf THE r1b " Regulatory Services n,Et,,STABLE. ; Thomas F. Geiler, Director MASS. �Q °o 0-39. Public Health Division PIED MAC A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 a Fax: 508-790-6304 December 18, 2007 Attn: Hyannis Fire Health Inspector Meredith E. Morgan conducted a rental inspection in accordance with Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector(and\or CO detector) violation(s): 195 Dunn's Pond Rd. Assessors Map-Parcel: (270-006): Smoke detectors in basement and on main level are not operable. Mere E. Morgan -Health Inspector Q:\Order letterMousing viol ations\Rental ordinanceUire Violations\FIRE TEMPLATE.doe f t r tom. t �kk lt a o "al a Y f't f + i 3 m m 1 � U i Ti E^ b t f {{ r " x f, t � ` waA $ T'„ i tip l p" � p � C3 j� I n ., 1{ •� a' a, { I f t Ao 7C 5 it "Mx t •d" h p (C r 9. a fit. - 4 f_ WWI � . co �{ a 1 f . k • i 3 ., > ��A. . k � t'lNii, t � .�� � ,fix R, •4'��,f,�[ t , �ya sll�1 .i � �c•at �i• .rt.�'�11"�•�'•.�f,R i .. �• r.t fY+Y ��"'�i�,�•„r.�+ '�t'�` ems. ak:. a l � '� ��EYfi L y�sF4�Y�1-ye��• G$¢��,�; K s a lit =- , *� 3 y ,.. fit. d o 4 4 0 IY ' ; III COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ti TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 'Z Oti CERTIFICATION MAP. PARCEL 00 Go Property Address: 1 LOT 2 Owner's Name: Owner's Address: Date of inspection: �3 n6H Name of Inspector: lease print c Company Name Mailing Address-1. 0,42OF Telephone Number• CERTIFICATION STATEMENT I certify that I have personalty inspected the sewage disposal system at this address and that the information reported -below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage.disposal systems. I.am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: .Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority . Fails 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: _ Notes and Comments ****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. Title 5 Inspection Form 6/15/20.00 page I � t Page 2 of l 1 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �&dawgoo� Owner: Date of Inspection: �,—`p, Inspection Summary: Check A,B,C;D or E/ALWAYS complete all of Section D A. S stem Passes: .~ �--. .V..I=have not found any information which indicates that any of the failure criteria described in 310 CMR 15.3303.or in 310 CMR,15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon,completion of the replacement or repair; as approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or.tank failure is imminent:System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): .broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 • � r Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: —� Owner: Date of nspection: �i��.�J2✓1. /7 / 0,3 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 C.MR15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any).determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply: _ The system has a septic tank and SAS and the SAS is within a Zone i 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, perfonned at a DEP certified-laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION(continued) Property Address: �tI Owner: v Date of Inspection: iL D. System Failure Criteria applicable to all systems: .You must indicate"yes".or"no"to each of the following for all inspections: Yes No/ fib 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 U Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply.. r�L 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 qualify analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A.copy of the analysis must be attached to this form.] I" (Yes/No.)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correcfthe failure. E. Large Systems: To be considered a.large system the system must serve a.facilitywith a design flow of 10,000 gpd to 15,000 gPd•. You must indicate either"yes"or"no"to each of the following: . (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: fCG�' .cl OwnerAnpectio'n ;; 1 � Date o : _ 7 3 Check if the following have been done. You must'indicate"yes"or"no"as to each of the.followinc: . Yes No Pumping.information.was provided by the owner,occupant,or Board of Health r/Were.any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period? Have large.volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out Were all system components,excluding the.SAS, located on site _✓ _ Were the septic.tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid, depth.of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface.sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes/. no V Existing information. For example, a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION - Property Address: ��(�c•/� q� Owner: Date of Inspectii;n: 4 FLOW CONDITIONS RESIDENTIAL ✓ Number of bedrooms(:design):- Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents:. ) Does residence have a garbage grinder(yes or no):✓'� l Is laundry on a separate sewage system -Xesor n�fif yes separate inspection required] Laundry system inspected (yes or no • Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or n,*.,2U- Last date of occupancy: Ow COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: !© Was system pumped as part of the in pection(yes or no If yes,volume pumped: gallons--How,was quantity pumped determined? Reason for primping: - TYP OF SYSTEM eptic tank, distribution box,soil absorption system _Single cesspool _Overflow.cesspool _:Privy Shared system (yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copyofthe DEP approval _Other(describe): Approximate a e of all compo ents, ate inst lied(if k own)and source of information: 0 Weresewage odors detected when arriving at the site(yes or no):.%�- 6 Page 7 of l 1 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART SYSTEM.INFORMATION(continued). Property Address: Q4�� O Owner: Date o-Inspection: BUILDING SEWER(locate on site paany Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: . Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: locate on site plan) Depth below grade: c (y,(!�� Material of construction: ✓concrete_metal_fiberglass polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: j0•S k(p' X 5 Sludge depth: n Distance from top of sludge to bottom of outlet tee.or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ---- Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: t11(Z/2 �cd° Comments(on pumping recommen�ons, t let and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert,evidence of leakage,etc.): A GREASE TRA�ocate on site plan) Depth below grade:_ 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:. Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection /.)003 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any i evdence of solids carryover,any evidence of 1eakage into or out.of box,etc.): i, . PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump ch mber, condition of ps and app rtenances,etc.): 8 1' Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: Date of spection: kz j4,)(,7 03 SOIL ABSORPTION SYSTEM (SAS): (/ (locate on site plan,excavation not required) If SAS not located explain why: Type _... ._._. leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches, number, length: /Teaching fields,number,dimensions: 155 '60 A c30'C x /O'�J 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.): a / —'6d )c L k/0"/ J _ 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 or no): - Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVJY. (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL.SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. c ` 4kv Owner:X&41 �4 Date of Inspection: ,,p /9//d0 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. � E r5 o 0 10 Page 11 of I 1 OFFICIAL INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ITA �Gs Owner: "�a D'ate.of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water /13 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) Accessed USG.S database-explain: You must describe how you established the high ground water elevation: 11 Permit Number: �7 Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: �(�✓z— D�h�S �� /� Lot No. Owner: h/ u Address: Q e Contractor: O/T�O %L'D�95 Address: �✓`~ ;�a9G///SJ�f Y / - G'/9,�'l��!15i�!//� Notes: STEP 1 Measure depth,to water table tonearest 1/10 ft. ............................................................. Date .............. .. . month/day/year STEP 2 Using Water-Level Range Zone _ and Index Well'Map locate site and determine: (A) Appropriate index well...................................... � ... �. OB Water-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level-for index well ........................... Tl� month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),.current depth to water level for index well (STEP 3)., and water-level zone (STEP 26) determine water-level adjustment.............................:...................:.......................................... STEP 5 . Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ....................................:...................:....................................................... ' Figure 13.--Reproducible computation form. 15 y. . S � 3 y Q . TOWN OF BASLE v LOCATION �+ Olt�y J d' fd� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /w ga/ aw 6cl Amp Admher LEACHING FACILITY: (type) A-rdfilifA 04-1 (size) 41JI34L ,NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: /Z /D —?2COMPLIANCE DATE:—Jj.a 00 . MSeparation Distance Between the: 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 IT s` �-17V fig go F-Y:�J-i • I Z 70-�®6 !� No. rr, _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYicatiou for )Dtgozar *pgtem Con!Aruction Permit Application for a Permit to Construct( )Repair( )Upgrade(t/)Abandon( ) U Complete System ❑Individual Components Location Address or Lot No. /)�— �, Owner's Name,Address and Tel.No. Z ee,y lal rveo elv Assessor's Map/Parcel Installer's Name,Address,and Tel.No. G� Designer's Name,Address and Tel.No. ;7 71��� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/111�a Other Type of Building Re P eNo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //Z2 gallons per day. Calculated daily flow c3,301 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /,57961 /-7e,9 j ype of S.A.S. ir % 4!'—'�064 Description of Soil 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 Certifi- cate of Compliance has been issued b this Bo d o Health. Signe Date Application Approved b Date Application Disapproved for the following reasons Permit No. 2 Date Issued 707 No. / yi Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: e's $. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS. ppricatton for Migpogar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( t/)Abandon( ) LS Complete System ❑Individual Components Location Address or Lot No. / / 5— j'Ju��g ®� �, Owner's Name,Address and Tel.No. 7 ee"IGll Tvo del,/ Assessor's Map/Parcel Installer's Name,Address,and Tel.No. L( Designer's Name,Address and Tel.No. AAr 40 771--�!W Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/(0 Other Type of Building t" ' �_OAZ'(_'No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //42 gallons per day. Calculated daily flow a3 e gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1S�� /ODD09111 ' Type of S.A.S. Description of Soil 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 Certifi- cate of Compliance has been issued by his Bo d o Health. / Signed Date Application Approved b Date L97 Application Disapproved for the following reasons Permit No. Date-Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CER ,that t7h On-s'te Sewage Disposal System Constructed( )Repaired( )Upgraded(t/� Abandoned( )by / d L4 at Llf��S © 1` D has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer -Designer—,--,: � B A The issuance of this perm ha f not d,onstrued as a guarantee that the�yste ft,�w-illll function as de/signed /J 0 w Date /75 Inspector A�/�'1 le'd r r9 `� r 1 0 --------------------------------------- No. . ,r Z�r--;7 7a ^e5 'C,0 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Zigpogar *pgtem (Congtru/ction Permit Permission is hereby granted to Construct( )Rep ' ( Upg�dde(v)Abandon( ) System located at / i Awzi�5 III t�'f' JyYr7°/�sr/'S and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this t. Date: ,e� Approved :Y. r '`•`1/6I99 NOTICE: This Form Is To Be Used For the Repair Of Failed Se� tic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUMON PERMIT(WTTHOIJT DESIGNED PLANS) 1, Areby certify that the application for disposal works construction permit signed by me dated �Z- concerning the property located at V'fe%Smeets all of the following criteria: v The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch- V/ There are no wetlands within 100 feet of the proposed septic system /7"dere are no private wells within 150 feet of the proposed septic system -L T'nere is no increase in flow and/or change in use proposed Y There are no variances requested or needed. /The bottom of the proposed leaching facility will not be located less than five feet above the ma.-dmum adjusted groundwater table elevation. (Adjust the groundwater table using the F:imptor 1-if method when applicable] the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed 5 P . leaching facility will not be located less than fourteen(14)feet above the ma.-dmum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface EIevation(using GIS information) B) G.W.Elevation 'L® +the MAX High G.W.Adjustment. Z ? Z z ; 7 DIFFERENCE BETWEEN A and B Z� SIGNED: DATE: Z < G (Sketch proposed p1m of system on back]. q;heft Wee mt i C �r D � I kb ) e- I Z73rNm % c lQ ' G( r; Cl- i TOWN OF B ;ITPLE LOCATION d 12�?`I� O!'�G SEWAGE # �Z VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1001641 AM Clvimbfr LEACHING FACILITY: (type) Z Llir rr-3 ' (size) IJ'�30L NO. OF BEDROOMS I BUILDER OR OWNER i PERMTTDATE: ! Z l&'9 '' COMPLIANCE DATE: boo Separation Distance Between the: 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 IT ; S'T `Z'�-•Icy !_i ,� St.wh y E? o :Y t; IZ. . L._