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Home My WebLink About0055 FOSTER ROAD - Health (2) 55Nautical Road Hyannis A=307 a Town of Barnstable Inspectional Services Department. . CAB Public Health Division MAM 1639. �� 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas.A.McKean,CHO March 2021: CGM Realty Trust Christopher Mazgelis TR 34 Willimantic Drive Marstons Mils, MA 02648' RE: ION'SEWER CONNECT DEADLINE EXPIRED . , .. . .� 51/55 Nautical..WAY,-Hyannis A= 307�240: Dear Property Owner, Your sewer connection deadline has passed. Please contact the Public Health Division Office to provide an update relative to the status of property'..s. connection to public sewer (i.e. contractor name, DPW sewer connection permit.number, anticipated connection date.) If you would like to request an extension, such request must be in writing addressed to the Board of Health (200 Main Street Hyannis,Massachusetts) or e-mail Sharon Crocker at: sharon.crockerMtown.Barnstable.ma.us within fourteen(14.) days. Sincerely yours, Karen Malkus-Benjamin Town of Barnstable Health Division Coastal Health Resource Coordinator karen.malkus(a)-town.barnstable.ma.us G� Town of Barnstable Inspectional Services Department • MIMNSTABMMAW Public Health Division 1639. `' 200 Main Street, Hyannis MA 02601 D MA'S A Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO October 21, 2019 CGM Realty Trust P.O. Box 518 Osterville, Ma 02655 IRtE 1'S 51 EWERC L�®N-laNk-.kaEt.�Gm,.Tar5I�wrr�s y.wNt�*•DmY:t+iEw. �EaF �E§,n`N5Wk X'3�P�aarI»i-Ruvr E+s4Dw:t e��K-.�1�yEr�� Dear CGM Realty Trust, Your July 30, 2019 sewer connection deadline has passed.' Please contact the Public Health Division Office to provide an update relative to the status of property's connection to public ,sewer (i.e. contractor name, DPW sewer connection permit number, anticipated connection date). If you would like to request an extension, such request must be in writing addressed to the Board of Health(200 Main Street Hyannis Massachusetts) within fourteen(14) days. Sincerely yours, Karen Malkus-Benjamin Town of Barnstable Health Division Coastal Health Resource Coordinator karen.mal kusatown.barnstable.ma.us phone: (508) 862-4641 F r r �I � O DQ O G V I " f r 1 pFWE lw,. Town of Barnstable Regulatory Services. snxxsrna , v MASS. Richard Scali,Director prEDM Public Health Division Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 1 '' Fax: 508-790-6304 Date: March 27, 2017 Bar(s): 79635 Name of Offender: Eric Mulford Location of Violation: 51 Nautical Road,Hyannis Date(s) of Violation: 10-20-16 Violation(s): Town of Barnstable Board Code § 54-5. Storage of garbage and rubbish, responsibilities of occupants. Facts: On 10/7/2016 the Health Division received a complaint regarding a trash problem. This consisted of trash being stored improperly in accordance to The Town of Barnstable Code § 54-4' ` Storage of garbage and rubbish. On October 13, 2016 Health Inspector James Parziale,RS met with said offender at said address. While at property said health inspector did observe a large amount of garbage and debris at ` this property. The said offender was advised on the proper storage of garbage within The Town of Barnstable. The said violator has been warned many times over a course of a year about this trash problem. On October 13, 2016 said offender was issued a ticket for non-compliance. This ticket was paidin the weeks to follow. A second'ticket(BAR 79635) was issued on October 28, 2016. This property is currently still not in compliance as letter is dated above. Respectful Submitted, i Timoth B. O'Connell, RS ; Health Inspector Town of Barnstable 200 Main Street Hyannis, MA 02601 (508) 862-4644 NAME OF OFFENDER _ y (!F�!✓; r R.. , - BAR 79629 J ��Y ADDRESS OF OFFENDER 1 �' L BARNSTABLE CITY,STStttATE,9ZIP/t� �rCCODE E PJA dF 3NE►q,• MV/MB REGISTRATION NUMBER tH �` OFFENSE I4..�i.t�-t, to r,� E; -a,r t-! 5 1 oft c s t. A( i�.��.. -7b,;�.aNLJ rEe 6141 dl >- TIME ND DATE OF VIOLATION Y LOCATION OF VIOLATION W NOTICE OF (A.M:'tjQ)0 ON 10163 201 to ?;3 )AO.^c't f a ir`�+"t o rs S SIGNATURE OFrENFORCING PERSON EN ORCI DEPT. BADGE N0. W VIOLATION C ..� ,/ J : ,.._ �, ,�uni OF TOWN �,,1�HEREBY ACKNOWLEDGE RECEIPT OF CITATION X a ORDINANCE In Unable to obtain signatu a of offender. ra— THE NONCRIMINAL FINE FOR THIS OFFENSE IS t 100 Date mailed 7 �.f w OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w REGULATION a (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, W before:The Barnstable Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, a Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. (2)If you desire to contest this matter in a noncriminal proceeding,jrou mayy do so by making written request to DISTRICT COURT DEPARTMENT,FIRST RR TA DIVISION,COURT COMPOUND,MAIN STREET, ARNSTABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or If you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature NAME OF OFFENDER �T;�� BAR 79635 , XI C. t� TOWN OF ADDRESS OF OFFENDER 1 ""(I r BRNSTABLE C TY,STATE,ZIP CODE dFI"E►qk, MV/MB REGISTRATION NUMBER V OF piS4fE NANA .F.q r �♦€/YVI E�' W9S. 163 LU TIME AND DATE OF VIOLATION LOCATION OF VIOLATION LU NOTICE OF � : A �. / P.M.)ON ;7 0� �rA'VI("A rv,, fti � �� VIOLATION S NQT1Y E ENF PERS N B ENFORCINGDEPT. BADGENO. W CD OF TOWN l'- I WERERY AC NOWLEDGE RECEIPT OF CITATION X a ORDINANCE Unable to obtain ignat a of offender. �d �, THE NONCRIMINAL FINE FOR THIS OFFENSE IS S Date mailed d " al.1 W OR YOU HAyt'THE FOLLOWING ALT NATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w REGULATION , You ma elect to a the above fine,either b appearing in arson between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, Q before: Uj The Barnstati el Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, �- Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. d V If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST If DIVISION,COURT COMPOUND,MAIN STREET 0Au STABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within'21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature i itizen Web Request Page 1 of 1 F (By 5TAB13 y Citizen Request Management t � Request ID: 57519 Created: 10/7/2016 10:14:05 AM Status: Assigned To Staff Assigned To: Parziale,Jim Health Office Anonymous: No Category: Chapter II : Housing Substandard E.C. Date: 10/24/2016 Created B Sousa, Vanessa Citations: Health Office Time Worked: 0.50 Response Time: 8.00 Request Location: 55 NAUTICAL ROAD Hyannis, Ma 02601 Parcel Number: Map: 307 Block: 240 Lot: 000 Request: Per Town Manager, please investigate above address. Request Work History: Entered on 10/13/2016 3:59:47 PM property in violation is 51 nautical. occupant has been warned numerous time and I gave him a print out of chapter 54 the last time there was a complaint at the property. citation issued { http://issgl2/InterhalWRS/WRequestPrintPub.aspx?ID=57519 10/13/2016 TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out Owner W�� (it-�5 Tenant Address 78� t L'U140 TIc- Address AWT%C,4(, Compliance Remarks or Regulation # Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities L e Aft 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 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 Vehicle we (max) Number of Persons Allowed (max) Person(s) Interviewed Inspecto�/� ...... If Public Building such as Store or Hotel/Motel specify here A M1 TOWN OF BARNSTABLE ' BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION j Date �,O !(A Time: In Out /I } Owner Tenant w Address 384 11)iLAAMtW-nc_ �NL Address 51 r�cf,G"t, Ab { AA is ,- U.. A4 - � Compliance Remarks or Regulation# Yes NO Recommendations 2. Ntchen Facilities 3. B throom Facilities PlLeh its) BA 4. Water Supply 5. Hot Water Facilities f 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and M ntenance of Facilities 10. Curtailment of Service 11. Space and Use L12. Exits 13. Installation and Maintenance of Structural Elements w T,14Ansects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal , 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed .art 8 ._.. "'q,~.'�4'""'r' �'!•�, "" + �� •�, *'APART III 37. Placarding of Condemned Dwelling; „ Removal of Occupants''*,Dem6lition Number of Bedrooms Number of Vehicles All'�ed (max)`` Number of Persons Allowed (max) , Person(s)�Interviewed .•a Inspecto y ✓ . ✓/J) If Public Building such as Store or Hotel/Motel specify here 4 4 Fax Send Report MAY-04-201712:04 THU Fax Number 915088624713 Name BARNST HEALTH Name/Number 915083620213 Page 2 Start Time MAY-04-2017 12:03 THU Elapsed Time 00'16" - Mode STD ECM Results [O.K] 7 TOWN OF BAfftNSTABLE 4. He,a th Division-200 Main Street-Hyannis,MA 02601 - FA-C A. D7— Date: S— I 1 ` - Nnmbei of pages including co - TO: FROM: Town of R arastable FlealthDivision Phone: Phone: 508-862-4644 Faxphoxze: Sog'3G)L- B�L13 Paxphonc: ' 508-790.6304 CC: [REMARKS: ❑ Urgent ❑ For your ❑ Reply ASAP ❑ Please comment review i TOWN OF BARNSTABLE Healt]i Division—200 Main Str6et- Hyannis, MA 02601 p�THETpk - P y F� s -`� s Date: IMMIX, y .MASS. 16jq.,>0 Number of pages including.cover sheet: TFD µPS TO: FROM: Town ofBarnstable " Health Division' Phone: Phone: 508-862 4644 Faxphone: Sag' Fax phone: 508-790-6304 CC: REMARKS: ❑ Urgent' ❑ For your ❑ RepIyASAP El -Please comment review d oF1NE la,. Town of Barnstable Regulatory Services * BARNSTABLE, 9 MASS. 039• Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date:May 4, 2015 - - Bar(s): 79635 (Dockett # 1725AC000131) Name of Offender: Eric Mulfurd . Date(s) of Violation: 10-28-16 Violation(s): Town of Barnstable Board Code § 54-4. To: Magistrates of Courts of Barnstable District Court. To whom it may concern: s As of May 4, 2017 said offender is currently in compliance with Town of Barnstable Codes § 54-4. Asa result the Town of Barnstable would like to dismiss above violations (bar#79635) and. will not be present in court on May 5, 2017. Respectfully Submi ed00 ; . t-� ?j; � Timothy O'Connell, RS Health Inspector Town of Barnstable 200 Main Street ` Hyannis, MA 02601 s 3 C{ { 'VIKMIE Town U Barnstable Barn r Regulatory Services Department AFAmedcal0 j +' BA1tNbTABI.E. � 9. ,0� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard Scali,Interim Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 1661 January 13, 2014 CGM Realty Trust PO Box 518 Osterville, MA 02655 IMPORTANT NOTIC Map & Parcel 307-240 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 51/55 Nautical Way, Hyannis, MA, to public sewer on or before 7/30/2019. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis: Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see enclosure R ORDER OF THE B ARD OF HEALTH Thom s McKean, R.S., C.H.O. Agent of the Board of Health ' Eric Q:\SEWER connect\Sample order letters for sewer connection\51 Nautical Way Hy Jan 2014.doc Y Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a:limited t me,of two years, only from-the:receipt of the DPW letter ,,vo ld proAde you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.ma.us/cdbg (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. yu i. lt\L°lu 1'yl v. Information on Licensed Sewer Installers is available on our web site at www.town.bamstable.ma.us/PublicWorksTech/sewerinstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors, please call Dave Anderson at (508) 790-6244. FOR'ANY QUESTIONS /ASSISTANCE: Len Go.beil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connect\Sample order letters for sewer connection\51 Nautical Way Hy Jan 2014.doc � � \J o Complete items 1,2,and 3.Also complete A. a e item 4 if Restricted Delivery is desired. ❑Agent o Print,your name-and address on the reverse ❑Addressee so that we,can return the card to you. B ceived b (P hted Name) C. Date of Delive o Attach this card to the back of the mailpiece, y iS �/� �/ s or on the front if space permits. ,�`� F D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery,address below: 0 No i Christopher Mazgelis g--- I 3. Se a Type I 3s84¢Willimantic Drive; w". ertified Mail 0 Express Mail StOriS Mills, MA'Q264.$ ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Mys trtee�}jverr2xtr� ) ❑Yes 2: Article wumber t „(IFansfe4 from service label) t" °7 014 12'0 0 0 0 0''1 0 3 56, g 7 6 5 PS Form 3811.February 2004 Domestic Return Receipt +02595-02-M-1540 i UNITED STATES ?t £ST#k►.3i.��'E 11 .; First-Class Mail Postage&Fees Paid _ _......._. USPS Permit No.G- • Sender': ease'print your name, address, and ZIP+4 in this box • Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 I I Certified Mai14 7014 1200 0001 0358 0756 Town of Barnstable �t Teti Regulatory Services 0 Richard Scali, Director ■A"srABLE WUS& Public Health-Division i639. �0 pTFDtAA�A Thomas.Mc'Kean, Director 200 Main Street, Hyannis, MA 02601 Christopher Mazgelis 384 Willimantic Drive Marston Mills, MA 02648 November 14, 2014 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION. F The property owned by you located-at 51 Nautical Road, Hyannis, was inspected on November 14, 2014 by Timothy.B. O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint received at The Town of Barnstable Health Division. The following violations of the State Sanitary Code were observed: 105 CMR 410.500.,Owner's.Responsibility to Maintain Structural Elements. The Window's within the kitchen have broken glass panes; back door is in disrepair and needs replacement. Multiple broken doors and holes within walls. The tile floor is cracked throughout kitchen area. The second floor tub appears to leaking and is causing damage to kitchen ceiling and multiple,light switch face plates are cracked or missing. You Are directed to correct the violations listed above within 30 days of your:receipt of this notice by-correcting above violations. You may`�request a hearing before the Board of Health if written petition requesting same is received within ten" (10) days after the date the order.is,served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. ,Should .you have any ;questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH o " as A. McKean, R.S., CHO Director of Public Health ,r' Town of Barnstable, ` Q:\Order letterMousing violations\51 nautical rd hyannis.doc Citizen Web Request Page 1 of 3 r * ] ) 1 r S.ARNS tAbLk- 14 TOWN\ connLogged In Citizen Request Management Thursday, November 13 2014 TOWN\oconneit Route to Users Search Requests Create Requests Reports Request Information Request ID: 51049 Created: 11/7/2014 3:13:56 PM Status: Assigned To Staff Assigned To: 'O'Connell,Timothy Health Office Anonymous: No Request Category: Chapter II : Housing Substandard edit Routine work: No Estimate: No edit Date scheduled: '. edit Estimated 11/24/2014 Change Estimated Oct November 2014 Dec Completion Completion Date: Date: [27 Tue Wed Thu Fri Sat 28 29 30 31 1 4 5 6 7 8 11 12 13 14 15 18 19 20 21 22 25 26 27 28 29 2 1 1516 Created By: Soto, Kathryn Priority: Medium edit Health Office Citation Numbers: edit Requestor Information Requestor Request Parcel Number Map: 307 !Block: 240 { 00Lot: 0 Parcel Looku) http://issg12/internalwrs/WRequest.aspx?ID=51049 11/13/2014 Citizen Web Request Page 2 of 3 Caller/tenant states house has issues with mold, wiring problems (electrical fire at an outlet recently, the person the landlord sent to come fix it says wiring needs to be fixed in the whole place)and there is a gap in the back door that is letting the heat out. Landlord had been informed Email: many weeks ago and has not taken action. Also housing informed tenant that neighbors in duplex have fleas and bed bugs and that they will be in her place next. Edit Requestor Information Track Request Progress Request Work History: Internal Note History: Entered on 11/10/2014 8:38:58 AM System entry on 11/7/2014 3:13:56 PM: by O'Connell,Timothy Assigned to O'Connell,Timothy I have an appointment on 11-13-14 update.delete Enter work progress: Enter internal note: (Viewed by everybody) (Viewed internally only) •h» rc-111, wv Spell Checker Spell Check fll Add document or image link: Brovse 'f` *You can also type in a folder name to see everything in the folder Current Links: Time worked on request: 1.00 j Response time: 8.00 I *Time entries are in hours. Examples of time entries: 1.25, 0.5, 0.75, 1, 3.5, 0.25, 0.10 http://issgl2/internalwrs/WRequest.aspx?ID=51049 11/13/2014 Citizen Web Request Page 3 of 3 I* Response time: Measured from the creation date to your first actions on the request. * Do not include nights, weekends, and holidays in response time for most departments. r Save changes rl Check to notify town employee below to review this request. Save changes and notify Health Office citizen* _— Crocker, Sharon i;- Close request -- - — — ---_._.___ C Brief message to reviewer:Close request and notify citizen* Lj *notify works if email address was given ! ' a Update r _ �' SpellrCheck Public Use: Printer Friendly Version Internal Use: Printer Friendly Version http://issgl2/intemalwrs/WRequest.aspx?ID=51049 11/13/2014 i TO OF BARNSTAB E 1000, LOCATION �f— W SEWAGE # l- �� VILLAGE W./.4,u,," C ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.-� ��e�vs`r��c icy.��r 4421E DS^� SEPTIC TANK CAPACITY f S 06 r fe LEACHING FACILITY: (type) C cU c v eele (size) Z �«y, NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: C 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 7- . � � �7--� a e r y . .► fit' _ � - tl 4f. C1 - el10 yaL+ �' SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS DELIVERY E Complete items 1,2,and 3.Also complete A. Received y(Please Print Clearly) B. Date Del ery item 4 if Restricted Delivery is desired. �JJ i Print your name and address on the reverse so that wp can return the card to you. C. Sig ure Attach this card to the back of the mailpiece, X ❑ja IAgent or on the front if space permits. ❑Addressee D. Is delivery address different f orn item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery addrei s below: ❑No 0 6 3. Service Type Certified Mail ❑Express Mai( 1 /� ❑ Registered ❑ Return Receipt for Merchandise S V ( ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2.Article.Number(Copy from service label) ,- ? i? a { }}1t }t it i}!}t i i .i ! ZOii 4 —Ii t ! —1 PAS Form 381 1 ,Julyi1999 t it t, #t t; Domestic Return Receipt 102595-00-M-0952 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • Board of Hl eft Town of Barnet" P.O.Box 634 Hyannis,Manadwsstte 02601 I M I 2'03 499 193 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Stre & qr - P Office. ate,& IP ode Postag Certified Fee 010 Special Delivery Fee Restricted Delivery Fee Ln - or). Whom Receipt Shown_ 'na to Whom& •r roared \ ° Q Retum Showing to.: 'fir Q Date,& ee's Addresl�r TOTAL P stage&� ,� $ Postmark of Da V) d I Stick postage stamps to article to cover First-Class postage,certified mail fee,and I charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service a window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return address of the article,date,detach,and retain the receipt,and mail the article. uO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,.Form 381',,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the O O addressee,endorse RESTRICTED DELIVERY on the front of the article. 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. O, �i 6. Save this receipt and present it if you make an inquiry, t o25s5-s7-I3-ot 45 n:. Z�203 499 194 US Postal Service Receipt for Certified Mail- No Insurance Coverage Provided. Do not use for International Mail See reverse Se toWn r n St glum r l•� P ce: ,atg„& IP C TYA Postagel Certified Fee ® - Special Delivery Fee M Restricted Delivery Fee Return Receipt Showing to Whom&Date Delivered a Return Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage)VI! , M Postmark$r kD .' a �ti Stick postage stamps to article to cover First-Class postage,certified mail fee,and P charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q) return address of the article,date,detach,and retain the receipt,and mail the article. uO 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a I RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of fhe C addressee,endorse RESTRICTED DELIVERY on the front of the article. Go ` M, 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. o u_ 6. Save this receipt and present it f you make an inquiry. 102595-97-B-0145 �oFTHEr�� Town of Barnstable o� Department of Health, Safety, and Environmental Services + BARNSfABLE. '"^MS. i639• Public Health Division ♦0 pr�D'AA�A P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health March 2, 2001 Shane Pacheco ' 309 Bishops Terrace Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE II,MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 55 Nautical Rd., Hyannis, was inspected on February 26, 2001 by Edward Barry, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code II,Minimum Standards of Fitness for Human Habitation were observed: 410:500 Rear door threshold rotten. Space between door and door frame of front and rear door in excess of 1/16". 410.500 Two (2) holes in ceiling of upstairs rear bedroom. 410-481 Building not posted with a twenty(20) square inch sign bearing name, address and telephone number of the owner. You are directed to correct the above violations within ten (10) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within ten (10) days after the date order is received. However,these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF HE BOARD OF HEALTH �omaMcKean Director of,Public Health Q:/health/ivpfiles/orderleded/pacheco .. .i'•,:.<t:y,--.R.,fi"w.I.I•.n.11:• '`u.••a'd J.'1.,,,... ..,^! - "-.�. , rs' �'p,�•Y.` - .,'-s�-.-rl•'rI. �r� - _ ..� , f FORM 30 &W HOBBSB WARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOW N DEPARTMENT c ADDRESS TELEPHONE Address - iP Occupant_ -- "" Floor - -Apartment No _—__._ _ No.of Occupants__" _ No. of Habitable Rooms - No.Sleeping Rooms.3 No. dwelling or rooming units_+ �_ No.Stories Na _e,and ad r e s s of owner, 1'Z_ '? ,,r 0 9 74 1�"'C oC1 � '� � I��^(%� r're� + i s�«x� Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. 48te- taws;-Perehese 7`'3'57oqlf 00'7' EDual`Ei rega�-arid•G:bst.'n"r is's7` ' �+t� D , ✓.* ❑ B ❑ F ❑ M Doors,Waa4aWs* Roof r 444" n;e Gutters, Drains: f Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hat$-Rviatz7,Wat Ce i l i n e-_ef oa,•„ ' f Hall Lighting: "" h r 4f,-A5- f* _-I- r {� 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 INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR rV 4A P . ' -°TITLE DATE �" , , TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. �1. 410.750: Conditions Deemed to Endanger or Impair Healt-i or Safety The following conditions, when found to exist in residential premises, shali be deemed conditions which may endanger or impair the heaith, 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 encanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 41C.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 withir 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. f — e s, The Town of-Barnstable 1leAlth Department i :u." 367 Main Strect; Hyannis; MA 02601 Office 508-790-6265 fi�� /'R' ` s�1 'G '�� Thomas A. McKean Direct or of Public Health FAX 50b-j7PP344 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00,_STATE SANITARY CUUE_II�_MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION The property owned by you located at '�Y �✓ � was inspected on 2, -,-; ► ',7#Y by �V�W,4--M P oaf health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code II, Minimum Standards of Fitness for Human Habitation were observed: tl You are recta o corre es io io wiatib t fo o . You are also directed to correct � � � yas within �� days/hours of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health a D y A Town of Barnstable �oZVE Tp Department of Health,Safety and Environmental Services �P Public Health Division } BMWSPABLE. * R.O.Box 534, Hyannis,MA 02601 9 MASS. Office: -4644 Thomas A.McKean,RS,CHO FAX: 508-°;90-6304 Director of Public Health r 1 TO CHRISTINE MAZGELIS 1330 PHINNEYS LANE HYANNIS MA 02601r105 ust 29, 2001 NOTICE TO ABATE VIOLATIO410.00 STATE SANITARY , CODE II MINIMUM STAND S OF FITNESS FOR HUMAN HABITATION Nl � AND THE TOWN OF BARNSTA LE RENTAL ORDINANCE ARTICLE 51 The property owned by you located at Ol Ocean Street Hyannis MA. 02601 was inspected on 08/24/2001 by Edward Barry , Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code II, Minimum Standards of Fitness foe Human Habitation were observed: 410-500; Water overflowed into the basement from the plumbing, flooded the basement to a depth of about 2 inches. Mold was observed at the celler wall up to a height of 30 inches. Apparently water discharged from the plumbing located in the Laundry Room in the basement. 410-351 Kitchen sink leaks water into the Music Room in the basement. 41.0-481 Bldg. Not posted with 20-sq. inch sign bearing the owners name, address, and telephone _ number. You are directed to correct the above listed violations above within Ten (10) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of -Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure,to comply with an order could result in a fine of not more than.$500. -Each.-separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A.McKean Director of Public Health Q:/health/wp iles/nuic#1 FORM30 �I� HOBBSB WARREN THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOW N 0 1 DEPARTMENT ADDRESS TELEPHONE A dress� � _.t r �,�' Occ ant. ' '` Floor -� P partment No. _ _— .. _ No. pants_ p No. of Habitable Rooms _.._�I 0.Sleeping Rooms No. dwelling or rooming units_— No. Stories " _ Name and address of ow..... l " /"� A ✓ril$r . � >: + # '� *2 jjr441 Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. StelDs,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: , Roof Gutters, Drains: Walls: Foundation: Chimney:, BASEMENT Gen.Sanitation: Dampness: Stairs: C .t 04' Li htin : r1 .e".> ' STRUCTURE INT. Hall,Stairway: / Obst'n.: Hall, Floor,Wall, Ceiling: Hall Lighting: Hall Windows: i HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: '' ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safet and Vents _ 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 Bedroom 2 f ,r�••� t Bed room_;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 ,, .4 - 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 '2 A.M. DATE 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 heaith, 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 41C.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 soread 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 Co-itrol, 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 heatirg 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. TOWIJ OF BARNSTAB E LOCATION SEWAGE # VILLAGE il ,01u iC ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. iLnv�rrc�cl i®a�-�.vr ��-5 DSO' SEPTIC TANK CAPACITY f S�Oc� Q% r LEACHING FACILITY: (type) C6 0 c� e�� (size) ft 9/ -c 7.Fa NO.OF BEDROOMSMS e/ic .w C`�Io BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 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 f A P 1 I f � r r ► I 74 � 1�r► � P� �1�T� t1 n 9A 1 1 .g. No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZippYtcation for Mie;poe;al bpgtem Congtruction Vermit Application for a Permit to Construct( )Repair(-<Pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. f 1—,sj S(1a" Owner's Name,Address and Tel.No. la►Assessor's Map/Parcel �,/O C.-- 6 `( Installer' e, dress, di Tel.Na— Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms�_ Lot Size sq. ft. Garbage Grinder(N9 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank fs ac; cJ, Type of S.A.S. oy r r Ae00 C ,Q v, ems Description of Soil Nature of Repairs or Alterations(Answer when applicable) c Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system r with h r vi i 1 f e Envir n ental ode and not to lace the system in operation until a C rtifi- in accordance th the p o s o t e 5 C p y p cate of Compliance has be issued b t ' d th. Sign d Date _. Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued Nlk i. No. /' U_r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer- T. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSFETTS 01ppYication for -Migaaf *p!5tem Construction Permit Application for a Permit to Construct( )Repair(grade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. s^�—S'S �(/(,�,,,+-Zpxw Owner's Name, Address and Tel.No. Assessor's Map/Pa cel 0 11 Instr' `• e, dress,�aj�dPTel.No�.e Designer's Name,`Address and Tel.No. " d rc l P�, C loan '# N C Type of Building: / Dwelling No.of Bedrooms Y Lot Size sq.ft. Garbage Grinder(A!9 r Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures 3 ` Design Flow gallons per day. Calculated daily flow a gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /s 4Te "J, Type of S.A.S. G'e r A 5t 6 w e-r P��k a :. C ' Description of Soil Nature of Repairs or Alterations,(Answer when applicable) , C ' t 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 provisionAb e Envir n ental Code and not to place the system in operation until a.0 rtifi; cate of Compliance has be issud h. Sign d: Date to Application Approved by -. Date .... v Application Disapproved for the following reasons 1 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 (x)Upgraded( ) ,Abandoned( )by . s ✓ �� ': .ti "T�uC. at _A :t W P has been constructed i accord nce with the prov' 'o}�of Title 5 the for Disposal System Construction Permit No. dated G—�y 27 — Installer r VC Designer _4A" The issuance of thi pe it ha not a construed as a guarantee that the to ill functi n esig n Date Inspector _ f --®-_: --®®®-------------------------------� No. � Fee T THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS _ Mi5pogal *p,5tem Conotruction Permit Permission is hereby granted to Construct( )Regair(k Upgrade( )Abandon System located at — 5 •� ? (Z),4 )�,IA1 Aj Aj and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her d>ty 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 thisZppait. f Date: i `l I�t Approved by CU__ (- 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, v s , hereby certify that"the application for disposal works construction permit signed by me dated (o /i� !� , concerning the property located at — S W;CA ( uJ q meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) ,S SIG DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert Q ^ 1 ✓ � zrh (� 4 1 O o 0 t Z .203 499 100 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse a Street&Numbe Post State, P ode Postage Certified Fee Special Delivery Fee Restricted Delivery Fee uO Return Receipt Showing to Whom&Date Delivered n Return Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees eq Postmark or Date tL W 0- I Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811 and attach it to the front of the article by means of the gummed ends it space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. C9 5. Enter fees for the services recuested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. �`5 6. Save this receipt and presen:it F you make an inquiry. 102595-97-B-0145 d i i FORM3o HOBBs&WARREN,INC. THE COMMONWEALTH OF MASSACHUSETTS /�`/f j��(�� BOARD OF HEALTH �,,,. , �I Aze Ii/mvi IcAl , CITY/iOWN W ,� :s An , I - , i"CA v DEPARTMENT PO4) _ 7!0/-t/r7( R C � i TELEPHONE Address �1 ,J r{ /l A b ! ), : f f i tl Occupant `� 1 N`, i.!vt x r' Floor Apartment No. No.of Occupa vts --- J No.of Habitable Rooms No.Sleeping Room, r - No.dwelling or rooming units- ��> � No.Stories.C`� / �ry Name and address of owner+ � , � f o-y � mi /AW "7 -- Remarks Reg. Vlo. 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 1 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 Livina 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 r Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: i' )(}GV ,- `{{�{ > ()// l { iY l _flr,� '"� ' A 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,r f 77 PENALTIES-OF PERJURY:" INSPECTOR TITLE r J i \ r ✓ (/ A.M. DATE l TIME /` P.M. THE NEXT SCHEDULED REINSPECTION _. Y{ j 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 these 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 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations 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 the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it 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) Shut-off and/or failure to restore electricity or gas. (D). Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A); 410.253(A), 410.253(B) and the lighting in common 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 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 an object, including garbage or trash, Which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to comply with the security requirements of 105 CMR 4110.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.6.02 which results in any accumulation of garbage, 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 lead-based paint on a dwelling or dwelling unit in :.violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. =(B) Roof,`foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or is"Oftent to health or dafety. (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 facilities 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 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 operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and 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,, gas-fitting, or electrical wiring standards that do not create an immediate hazard. .(r)_ 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. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition 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. 1 PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 307 240- - Account No: 219249 Parent : Location: 51 NAUTICAL RD HYANNIS Neighborhood: 61AC Fire Dist : HY Devel Lot : 4 Lot Size : . 18 Acres Current Own: CHAMSARIAN, E MATTHEW State Class : 104 129 WINDING BROOK ROAD No. Bldgs : 1 Area: 2160 Year Added: SO YARMOUTH MA 2664 Deed Date : 050196 Reference : 10193071 ' January 1st : CHAM ARIAN E MATTHEW Deed MM DD: 0596 Deed Ref : 10193071 Comments : Values : Land: 20700 Buildings: 84600 Extra Features : Road System: 51 Index: 1067 (NAUTICAL ROAD ) Frntg: 100 Index: ( ) Frntg: Control Info: Last Auto Upd: 020997 Status : C Last 'TACS Update: 110196 Land Reviewed By: Date : 0000 Bldgs Reviewed By: ML Date : 0488 Tax Title : Account : Taken: Account Status : Hold Status : Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [307] [241] [ ] [ ] [ ] f m SENDER:p I also wish to.receive the ■Complete items 1 and/or 2 for,additional services. w ■Complete items 3,4a,and 4b.'• . following services(for an d ■Print your name and address on the reverse of this form so that we can return this card to you. extra fee): ai ■Attach this form to the front of the mailpiece,or on the back if space does not t. ❑ Addressee's Address permit. d m ■Write'Retum Receipt Requested'on the maiipiece below the article number. 2. ❑ Restricted Delivery W c ■The Return Receipt will show to whom the article was delivered and the date delivered. Consult postmaster for fee. v 3.Article Addressed to: 4a.Article Number Z ,203 r .Service Type 0 ❑ Registered Z Certified cc �� a �, Giv ❑ Express Mail ❑ Insured I ¢ 'T ❑ Return Receipt for Merchandise ❑ COD o 7.Date of Delivery ' oz� lv1 0� - } 0. �uj 5.R ived By:(Print Name) 8.Addressee's Address(Only if requested c LU f�� G �fayil ,� and fee is paid) F +) c 6.Sign e:(Addressee or Agent) I a°, i X i • PS Form 3 11,"December 1994 toz5s5-s7-s-o»s Domestic Return Receipt First-Class Mail UNITED STATES POSTAL SERVICE Postage&Fees Paid LISPS 4 Permit No.G-10 • Print your name,address, and ZIP Code in this box 0 Public Health Dividon Town of Bamstable P.O.Box 534 Hyannis, Mamdusevs ow , I I ti- RECEsvEO , Commonwealth of M=ochusetts a {-- r„John Graci Executive Office of EnvUonmental Affairs APR 2 3 1996r • D.E.P. Title V Septic Inspector Department ®f t TM 44,A0. BoX 2119 Environmental Pteti®!� T `attcket, MA 0253E William F.Weld �508) S 6$13 ,. F. 6 Trudy Coxe w 8rerelary,EOEA tt � David B. 8huhs. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ` Property Address: 5,' �� 'V Qao�\C.�Q. � j t 3s"oYOwner: Date-of Inspection: (If different) Name of Inspector. Company Name, Address and Telephone Number:, CERTIFICATION STATEMENT I'certify that I have personally inspected the sewage.disposal system at this.address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience to the proper function and , maintenance of on-site sewage.disposal.systems. The system: k _ Conditionally Passes Needs Further Evaluation By the local Approving Authorih Fails = t, Inspector's Signature: Date The System.Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or hasRa design flog, of 10,000 gpd or.greater, the inspector and the system o�+:nersha1Lsubmit the report to the appropriate regional office Of the Department of Environmental'Protection. •` The original should be Beni to the system owner and copie. sen; to tier"Liner, if applicable and the appro,ing au:f,ority. INSPECTION SUMMARY Checo 8, C, or. D: AI SYSTEM PASSES: �have' ot found any information ,which indicates that the system violates any of the failure criteria as defined to 310 CMR 15.303, Any failure criteria not evaluated are indicated below. BI SYSTEM CONDITIONALLY PASSES.. One or more system components need to be replaced or repaired. The system, upon completion of the replacement, or r�ePair. passes inspection. Indicate yes,no,or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not)' The septic tank-'is metal, cracked, structurally unsound, shows substanpal"infiltration or exfiltration; or tank"(a�lure is imminent The system will pass inspection tt the existing septic5.tank is replaced with a conforminit'septic tank as approved by the Board of Health. 'ems (revised 6/15/951 _ One%Mf tsr 8tnet ` • Boston,Massachusetts 02108 • n�c(s1 ast;-�a� .. T:I•�ne(6171292-saoo PnN d on RwycW P*61 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t CERTIFICATION,lcontinued) Property Address: Owner: Date of Inspection:, « B)SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the.distribution box is due to broken or obstructed pipe(s) or due to a broken, ettled or uneven distribution box. The system will pass inspection if(with approval of he Board of Health): broken pipe(s) are replaced - obstruction is removed distribution box is levelled or replaced. The system required pumping more than four times a,year due to broken or obstructed,.pipe(s). The system, will.pass inspection if(with approval of the Board of Health): broken.pipe(s)are replaced obstruction is removed, ~ « Cl FURTHER EVALUATION 15 REQUIRED BY THE•BOARD.OF HEALTH: ` ?� a4P ,.� Conditions exist which require further evaluation by.the SoIard of Health in order to determine if the systemyts,fa ling to.protect the public health, safety and the environment. ]) . . SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THE SYSTEM IS NOT FUNCTIONING. IN A MANNER; i WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE:ENVIRONMENT: a 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) SYSTE.M WILL FAIL UNLESS THE BOARD`OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM is FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC,HEALTH pAND SAFETY AND THE E'��'IRO -MENT: 1nP wclPm ndrd %eullc lank dnu pun ausorpuon system t4nd 1$v.tthill (Uv feet tv.o $4ina.c '.:aiC $u�j,:� yr ✓u:afr" tc a" surface ea supply. The ` n ha eptic tank and.soil absorption'systeni and is within a Zone I of a public water supply well The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well The system has a septic tank and soil absorption system and is less than 100 feet but.So feet or more from a private water supply well, unless.a well water analysis for coliform bacteria and volatile organic compounds indicates that the.well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen'is equal'to or less than S D] SYSTEM FAILS: I have determined that the system violates one~or more of the following failure criteria as defined int310 CMR 15.303.`"The basis for this determination is identified below: The Board.of He1ealth should be contacted to determine what will be necessary.to correct .«.... .. - 1`. the failure. s.. Backup,of,sewage into faaltry`or system component due,to an overloaded or clogged SAS or cesspool rt Discharge or ponding of effluent to the surface of,the ground or surface urface waters due to an overloaded orclopged<SA5 or cesspool: r (revised'8/15L.95), K'< SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D) SYSTEM FAILS(continued): 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 1/2 day flow. Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System; cesspool or privy is below the high groundwater elevation. . Any portion of a cesspool or privy is within 100 feet of a surface water supply or.tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion'of a cesspool or privy is within 50 feet.of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet,from,a.private water.supply,well with no. acceptable water quality analysis. If the well has been analyzed to be acceptable,_ attach copy of well water analysis for. coliform bacteria, volatile organic compounds;ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply,to large systems in addition to the criteria above: The design floe of system is 10,000 gpd or greater (Large System) and.the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) ora mapped Zone ll of a public water supply well The owner or operator of any such system shall bring,the system and..faciliry into,full compliance„with,the.groundwater treatment program requirements of 314 CMR 5,00 and 6.00. Please consult the.local regional office of the Department for further information. (revised 8/15/95) 3" f 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property ddress: 5,' �S Nav�iLa-Q Owne ,1 Date of Inspe jon:�. Check if the following.have been done: ,yj�trf 1ping information was requested of the owner, occupant, and Board of Health. �$ of the system components have been pumped for at least two weeks and the system has been receiving normal (low rates- during that period: Large volumes of water have not been introduced into the system recently or as part of this inspection. ` iV*built plans have been obtained and examined. Note if they are not available with N/A. 4 facility or dwelling was inspected for signs of sewage back-up. ' y 4m. system does not receive non-sanitary or industrial waste flow: _L,14e.site was inspected for signs of breakout. L- F ystem components, excluding the Soil Absorption System have been located on the site. _,Jbe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,.material of construction, dimensions, depth of liquid, depth,of sludge; depth of scum. �e size and location of the Soil Absorption System on the site`has been determined,based on-existing information or app.rozi mated.by.non-intrusive methods f�[,Ir., p.,•,.+n•. in.f non-irantc, if d,iffprPnt irnm ownprt were provided with information on the proper maintenance of Sub- - Surface Disposal System. irevised 8/15/95) 4 SUBSURFACE SEWAGE,DISPOSAL SYSTEM;INSPECTION FORM PART C SYSTEM INFORMATION Propert .A Tess: Owner` �,, } Date of Inspection:?1 � R fLOW CONDITIONS . RESIDENTIAL: k } Design flow: 'b gallons Number of bedrooms orb 12 b��a`(IS :`'` 5 Q Number of current residents: a Garbage grinder (yes or no):_��' 0 Laundry connected to system (yes or no): C Seasonal use(yes of no):_Ztj Water meter readings, if available: Last date of occupancy: t COMMERCIAUINDUSTRIAL• Type of establishment: .. Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no),' Non-sanitary.waste idischarged. to the.Title 5.system: (yes or no)- Water meter readings, if available: Last date of occupancy: OTHER: (Describe) .. .,.; Last date of occupancy: _• . k GENERAL INFORMATION r , PUMPING RECORDS and source of information:. e m v S c,st cies�; �r N\� A0055- System pumped as pan of inspection:(yes or no3�.. If yes, volume ptimpeii . 3C gdlloris�(j%A (�C C��- , Reason for pumping., . f . TYPE OF SYJAM eptic,tank/d.istn but i on,box/so„i1,Absorpt ion,system„ , Single cesspool . Overflow,cesspool {. Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components; date installed (if known) and `source of inforration. ------ Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/951 5. h. SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM,INFORMATION (continue Prope ress: —SS Owner. l-►1 Date of In e .". !""1'�lob Q(p •` , ; ' ' SEPTIC TANK:✓- (locate on site plan) - Depth below grade: Material of construction: %,1roncrete' metal _FRP_,other(explain) i Dimensions: t\ ► 11 �q" 1-1 _ Sludge depth:_�� Distance from top of slugFe to bottom of outlet tee or baffle:��l r -Scum thickness:_ LA_ �11: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence pf leakage, etc.) 1 NN L V Ll GREASE TRAP: (locate on site plan).. Depth below grade: Material of construction: _concrete _metal _FRF_other(explain) Dimensions: Scum thicknen,, Distance from top of scum to top of outlet tee or baffle: 'Distance from bottom ni croom to bottom of outlet tee or baftle: a:, •, Comments: • . r ...�. .� ' / ._ _ (recommendation for pumping, condition of inlet and outlet tees or baffles, depth'of Uquid level in relation.to outlet invert, structural. integrity, evidence of leakage; etc i (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION.FORM PART C SYSTEM.INFORMATION(continued) Property ress; �— SS Owner: � . , l.. Date of Inspe 1 i LA `^ (('0 TIGHT OR HOLDING TANK:211�A „ (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP _other(explain) Dimensions: Capacity: Rallons Design flow: aallons/day Alarm level,- Comments: ., � .. •. _ .. _ ., _ (condition of inlet tee, condition.of alarm and float switches, etc.) DISTRIBUTION BOX:�� (locate on site plan) Depth of liquid level above outlet invert: ` Comments: (note if level and distriuurtur..'i5 equal, e,;dence of solidi ciar):,,er, e�idence of leakage into or out of box, etc.) PUMP CHAMBER: .. (locate on site p)an) Pumps in working order.(yes or no) Comments: (note condition of pump chamber; condition of pumps and appurtenances, etc.) (revised 8/15/95) 7. SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION,FORM. PART C . SYSTEM INFORMATION;(continued) Prope dress:. Owne Date of Jnspectiolt`t 1 SOIL ABSORPTION SYSTEM (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive method ) ' If not determined to be present,.explain: Type: leaching pits, number: leaching chambers, number:,_ leaching galleries, number: leaching trenches, number,length: ' leaching fields, number, dimensions:' overflow cesspool; number. i Comore ts: (note condition of soil, signs of hydraulic failure, level of p9nding, condti n i o vegetatfon,etcJ �! A .CESSPOOLS: (locate on site plan) q „ Number and configuration:. Depth-top of liquid to inlet invert: Depth of solids layer' Depth of scum layer: Dimensions of Icesspool: Materials'of construction: Indication,of ground,•,a:c .. inflow (cesspool must.be pumped as part.of inspection) Comments: (note condition of soi(;signs of hydraulic failure, level.of ponding, condition of.vegetation,etc.) - PRIVY: t Y•c (locate on site plan)- Materials of construction: `. . ..- _... Qarnensions. Depth.of solidsc Comments: (note condition of..soil, signs of,hydraulic failure,..leveI.of;ponding,,c9nditjp .of Ye On,:gtc - - - 8 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C . SYSTEM INFORMATION (continued) Prope ess: �—�. GvJ NC-p-Q-- Owner. �J Date of InspectQn6 SKETCH OF SEWAGE DISPOSAL.SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' { DEPTH TO GROUNDWATER Depth to groundwater. � —.feet method.of determination.or approximation: ,�SGS (' (revised 8,/1.5/95) 9 _ t r