HomeMy WebLinkAbout0020 FOURTH AVENUE (HYANNIS) - Health -- - HyaruiisPort
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,Jun 20, 2017 00:31 HP Fax page 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required for every West Hyannisport MA 02672 6-13-17
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important,Whenfill A. General Information pt1un11rp„
forms R rn aya`�ySN OF RI
on the computer,
out
on tter,
use only the tab 1. Inspector: '
key to move your ;
cursor-do not James D.Sears g JAMES N s
use
SEARS
key,the return Name of Inspector x�*;• :co;
Capewide Enterprises �. �••••o o
Company Name �i,!F' ••• G��
153 Commercial Street
Company Address
Mashpee MA 02649
Chy/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-13-17
,affspector'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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform In the future under
the same or different conditions of use.
t5lns.doo•rev.e116 Title 5 official Iispection Form:Subsurface Sewage Dlaposal System•Page 1 of 17
A, vs
dun 20, 2017 00:32 HP Fax page 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required for every West Hyannisport MA 02672 6-13-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal. Tank and two pit's.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
i
t5ins.00c•rev.6/16 Title 5 Offidet Inspection Form:Subsurface Sewage Dlwposal System•Page 2 of 17
Jun 20, 2017 00:32 HP Fax page 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
\V�zj
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owners Name
information is West Hyannisport MA 02672 6-13-17
required For every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health).-
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing.to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner'whlch 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
' - tSins.doc•rev;&16 Title 5 official Inspection Form:SUbeUAace Sewape Disposal System•Page 3 of 17
Jun 20 •2017 00:32 HP Fax page 21
.C\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required For every West Hyannisport MA 02672 6-13-17
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2, System will fall unless the Board of Health(and Public Water Supplier, if any)
determines that the system Is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well`*.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all Inspections:
Yes No
❑ ® 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
NA ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in is less than 6" below invert or available volume is less
than day flow P
t5ins.cloc•ray.6r16 Title 5 OBldaf Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Jun 20 2017 00:33 HP Fax page 22
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
r
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
requinform
r don is for every West Hyannisport MA 02672 6-13-17
required
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal collform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system falls. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.aoc-rev.6116 Title 5 Official Inspection Form:Subsur'ace Sewage Oisposet System•Page 5 of 17
,Jun 20, 2017 00:33 HP Fax page 23
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner -
Owners Name
information is required for every West Hyannisport MA 02672 6-13-17
page. CitylTown State Zip Code Dale of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): NA Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc-rev.6116 Title 5 Official Inspection Forth:Subsu?ata Sewage Disposal System-Page 6 o1 17
dun 20 ,2017 00:34 HP Fax page 24
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
Information is required for every West Hyannisport MA 02672 6-13-17
page citylrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal Tank and pits
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2015-80,000Gais
g ( y g (gib)) 2016-136,000GaI s
Detail:
Sump pump? ❑ Yes ® No
6-1-17
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sci t., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
I
i Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface sewage oisposal System-Page 7 of 17
Jun 20, 2017 00:34 HP Fax page 25
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required for every West Hyannisport MA 02672 6-13-17
page. Cityrrown State Zip Code Date of Inspedion
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
• r
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ InnovativelAlternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
15ina.doe•reV.6/16 Title 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 8 of 117
Jun 20 2017 00:35 HP Fax page 26
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required for every West Hyannisport MA 02572 6-13-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cant.)
Approximate age of all components, date installed (if known)and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate an site plan):
Depth below grade: 22
feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4"PVC SCH -40.
Septic Tank(locate on site plan):
'
Depth below grade: 1
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000Gal. Precast H-10
Sludge depth: 2"
t5ins.doc-rev.6116 Tltle 5 Official Inspection Form:Subsurface Sswalre Disposal System-Page 9 of 17
,Jun 20, 2017 00:35 HP Fax page 27
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required for every West Hyannisport MA 02672 6-13-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 17
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tank at working level. Tank and covers at 1' below grade. Inlet baffle w/two outlet tee's. No sign of
leakage or overloading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
15ms.doe-rev.6/16 Title 5 Offiael Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17
Jun 20, 2017 00:35 HP Fax page 28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required for every west Hyannisport MA 02672 6-13-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain);
Dimensions:
Capacity:
gallons i
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches, etc.):
•Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Jun 20, 2017 00:35 HP Fax page 29
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
owner Owner's Name
information is West Hyannis
required for every port MA 02672 6-13-17
page. Cftyrrown State Zip Code Date of Inspection
Dr System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No Box
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc,):
I
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5hs.doe•rev.6116 Title 5 Official Inspection Fame:Subsurface Sewage Disposal System-Page 12 o1 17
Jun 20. 2017 00:35 HP Fax page 30
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required for every West Hyannisport MA 02672 6-13-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
' ® 2 leaching pits number:
❑ leaching chambers number:
Cl leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two 1000 Gal, precast pits. pits are 18" below grade w118"water. stain line at 2'off
bottom, No sign of over loading.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ine.doc•rev.6116 TIIIe 5 Official Inspeclon Form:Subsurface Sewage Disposal Syetem•Page 13 of 17
Jun 20.2017 00:36 HP Fax page 31
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required for every West Hyannisport MA 02672 6-13-17
page, Cityr town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15ins.doc-rev.6116 Title 5 Official Ineoection Form:Subsurface Sewage Disposal System-Pape 14 or 17
Jun 20, 2017 00:36 HP Fax page 32
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required for every west Hyannisport MA 02672 6-13-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
ptic
A AFAR
I
e t
0
� 0
a 3
13-a
13-i/= .y9'
t5lns.doc•rev 6/16 Tine 5 official inspection Form:Suoswrrace Sewage Disposal System•Page 15 of 17
Jun 20, 2017 00:36 HP Fax page 33
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information is required for every West Hyannisport MA 02672 6-13-17
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to(Fgh ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you.established the high ground water elevation:
Auger T.H. at 11' no G.W.. Bottom of pit at 7'6" below grade. Bottom of pit at 3'.6"above T.H.
Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5lns.doc•rev.6/16 Title 6 official inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Jun 20. 2017 00,37 HP Fax page 34
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Fourth Ave.
Property Address
Ausra Bladyte
Owner Owner's Name
information for
oe every west H annis
required Y port MA 02672 6-13.17
page. Cdyrrown State Zip Code Date of Inspectlon
E. Report Completeness Checklist
i
® Inspection Summary; A, B, C, D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
i
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
t5ins.doc•ray.6116 TWe 5 Official to speAion Form:Subsurface Sewage Disposal System•Pape 17 01 17
10/13/2005 10:35 5084205553 YANKEE SURVEY PAGE 01
E-CLLN ID AT
APPLICANT, A USRA BLAD?TE TO TYN.' REST 11 A.NIVISFORT
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IF
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FIRST h'O.RIZON HOME L�AN.S Bank Ilse only
T110 location of the building shown dOPs _,YOE fall wit)lin a special flood hazard zone, PLAN REF
Pet taped inspection it Appt.Ars the lacotfOA of dNelling does __-- conform to the local by-JAw,o --
i fn effect at the time of construction. wf0i respoct to horlaonial dimensional setback rrt7W.rrrn,- SC 1' _ _�0 FT,
or 0 exrmpt frdln walabon rnPgrcrm�n4 action under *3vq. Crnrrnl [4rvs $c Ch. 40A - ,, -
Da le:
PI.,F,>l,SE NOTE The etruc[vrrs nn this fnapectlon trcrr Inrotrd by Gape not irsfn,mrnt and are approximate only. An actual survey is necessary
for a prrcfse determination of thr building location end rnrroachments if any exl-st, ritber rvav across property /inns. This inspection must, not
be used for recardlne purpavnv or for use in preparinv det+d descriptions and meat not be used for variance, or bldlding•plan purposes. 17ris
inapnrtinn must not be used to lnrgte ArvpertY lines. yrrifir-quon of building loentio—,, pmpertv.11ne dimensions, f—cvry or let rnnfyv..»totlnn can
only be rfrrnmplishGd by Al! accurate inFfnrnnnt sunny tthich mny rrfjrct different inrormnlinn than what• is shorn hereon. Thir inaprcUn.n Ls not
to hr, used for any purposes othrr than mcr]tggagL- Y'nh[/mr. .S/trrvayra�ccspts no respon-ci});lily for damages
rees�ultitinTg rrcm cnid reliance.
PHONI,' u0B-490-d055 �'�AN��d-/L_I S11.. V ) �Y0-/V,Y�/L1 A �' T,3
OWT 1, 40 INDUSTRY RD MAI?_sTOIVS MILLS,' MA Or-'?64H 3817015 BIM
r
L.UMMUN WEALTH OF MASSACHUSETTS
* EXECUTIVE OFFICE OF.ENVIRONMENTAL AFFAIRS
' DEPARTMENT OF ENVIRONMENTAL PROTECTION
201?6 JAN 31 ~A"A 10: 09
TITLE 5 DIVISIM!!
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM'FORM"'
PART A
CERTIFICATION
Property Address• Q L4 -� (� C', J�,��7� 1 r� d"ykf
Owner's Name: G Co �"k.f«lX1
Owner's Address:
Date of Inspection: 62
Name of Inspector: lease print) �� ��
Company Name: �o
Mailing Address:
Telephone Number.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved.system'inspector pursuant to Section 15340 of Title 5(310 CMk 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority.
Fails
Inspector's Signature: Date: .O2 Z3j(9 S
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
� I
**".*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 6/15/2000 page I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
i PART A
CERTIFICATION(continued)
Property Address: __ �% A J
0
Owner. ,j C U,n
Date of Inspection• 2 Z
Further Evaluation.is Required by the Board of Health:
Conditions exist which require fiuther evaluation by.the Board of Health in order to determine if the syste
is failin protect public health,safety or the environment..
1.. System ill pass unless Board of Health determines in accordance with 310 CMR 15.303(1 that the
system is functioning in a manner which will protect.public health,safety and the en ' onment:
_ Cesspool or vy is within 50 feet of a surface water
_ Cesspool or pri is within 50 feet of a bordering vegetated wetland or a salt m
2. System will fail unless the Board of ealth(and Public Water pplier,if any)determines that the
system is functioning in a manner that pro cts the public health afety and environment:
_ The system has a septic tank and soil abs tion syste (SAS)and.the SAS is within 100 feet of a
surface water supply or tributary to a surface wa suppl .
_ The system has a septic tank and SAS and the A is within a.Zone 1 of a public water supply.
The system has a septic tank and SAS an e SAS is in 50 feet of a private water supply well.
_ The system has a septic tank and S and the SAS is less th 100 feet but 50 feet or more from a
private water supply well**.Method d to determine distance
"This system passes if the well w r analysis,performed at a DEP certi laboratory, for colifonm
bacteria and volatile organic.co pounds indicates that the well is free from ution from that facility and
the presence of ammonia nitr gen and nitrate nitrogen is equal to or less than.5 p ,provided that no other
failure criteria are trigger A copy of the analysis must be attached to this form.
i
3. Other.
i
3
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:Lo11^ A-J e_
Owner. v V,\
Date of Inspection: S
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
_ Were any of the system components pumped out in the previous two weeks?
_ Has the system received normal flows in the previous two week period?
.� Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and.examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of.break out?
_ Were all system components,excluding the SAS,located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner).provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes n
— Existing information.For example,a plan at the Board of Health.
J _ 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
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Q "4 v t
Port
Owner. Ko j CAA c. - Y\
Date of Inspection: Z 0
BUILDING SEWER(locate on site plan)
it
Depth below grade: r�
Materials of construction: cast iron 40 PVC 1/other(explain):
Distance from private water supply well or suction line: _ 1:2L"I N
Comments(on condition of joints,venting,eviden a of leakage,etc.):
e�.k -F lA fv co �f i �orx' �( D�� �n o
SEPTIC TANK:_(locate on site plan)
Depth below grade: ���
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:. C, �r
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: rdY�
Distance from top of scum to top of outlet tee or baffle:_' d 1 e J.e f g r rn v S c 'JS
Distance from bottom of scum to bottom of outlet tee or affle:�A'' '�"
How were dimensions determined: 12 f n tj e
Comments(on pumping recommendationi,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
• 7
0 Vr rl �r e en.o' eJer
J
GREASE TRAP: (locate on site plan)
De below grade:y
Materia onstruction:_concrete_metal_fiberglass__polyeth le
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top o et tee or baffle:
Distance from bottom of s bottom of outlet tee or baffle:.
Date of last pumping:
Comments(on pu mg recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address:'2 O A� J e-
o�.
Owner. C C,kc 6all
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
' leaching pits,number. 1 to 00 o c-
leaching chambers,number
leaching galleries,number
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.Z
d('. W I �l" S &v► n h e 5 SC�i'yt
e fi [A-- CA VA_ S o - o- �:, 1 v
SSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Numb and configuration:
Depth—t of liquid to inlet invert:
Depth of soli er.
Depth of scum lay
Dimensions of cesspoo .
Materials of construction:
Indication of groundwater inflow or no):
Comments(note condition of soil,si hydraulic fai ,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site pl
Materials of construction-
Dimensions:
Depth of solids:
Comments( e condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc):
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:2 0
n �r
Owner. \yj-fx
Date of Inspection: -Z S
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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 USGS database-explain: re j- — 2 `A
Yo must describe how you established the high ground water elevation: t
V
6 0 -a
I1
J TOWN OF BARNSTABLE
LOCATION 0-0 ,—r /¢ SEWAGE #
li .. sy�
VILLAGE �r j e ASSESSOR'S MAP & LOT
17
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS W
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private WatetASupply Welland Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetlan&pd Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
100, 00' ..
LOT 215
=_=_ 4ck E-
o �
a
.LOT 2
100, 00' 77
-`J Y THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /
-, I p �¢
Appliration -for Bhipoaittl Marko Tanot urtion Vrrniit�
Application is hereby made for a Permit to Construct ( ) or Repair (1-1 an Individual Sewage Dis
System at
G�YIVI�I S /a g/7
c io :Addr s or Lot No.
` P Ow r dress
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ---------------------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width-------------------- Total Length____________----__ Total leaching arca....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date---.........------------------------....
Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water........................
�r4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a
O Description of Soil---- _
x
U .....---•--......-•-•-•-----•---•----------------------------------••--...-•----•...........-•--•---•--...................-------•••-----..............------------------•._..._.............------------
W
x :--------------------------- ------•• --------------
U Nature of Repairs or Alterations—Answer when applicable._..'� -. . . - ------_ _�� T
---------•--------s _.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—'The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issued by the and f alth.
Sied. -----------•------------------------- ----�3. _./�`.�....
Date
Application Approved By..... Q� .. (, - ---------
Date
-----------------------
Application Disapproved for the following reasons---------------••--• -------°----------------------------........------------'--------...---.....---------
•-•--••-•-•--------•---•--•-•---•-•----•--•-------------------------•--------------••--------••-------•--•-•---•----•-----•-•---------•----....-----------------...---------...---------•--....------•--
Date
PermitNo.......................................................... Issued.........................................................
+�.ra r••w �::.i i'. u; y>..x?. . .. . .. . .. Date
No.._.....••• -•---- R x.,"�'.ro....
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............O F.��� G! !����G / ................................
Appliratinn 'fur Disposal Works Tonstrnrtinn Prrntit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
.... ...... ............................... ................................................................................................
oc ion-A dr - L�� r��or Lot No.
dress
r
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling' No. of Bedrooms............................---..--..........Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons..--.----------.-------.-.-- Showers ( ) — Cafeteria ( )
QOther fixtures --•------------------------------•-•------......---•--...............................................................................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width..---........... Diameter.--.........---- Depth.......----.....
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
r Seepage Pit No--------------------- Diameter................---- Depth below inlet----................ Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
.Percolation Test,Results Performed bY--=----------------- ------------------------------------------------ -- Date
a
Test Pit No: 1-----------------minutes per inch , Depth of "Pest Pit...............----. Depth to ground water...---..-----.---.......
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit................---- Depth to ground water-..--.-------.---.--_-
W ----- --- ----
Description"of Soil-------- `1- L! .................
U ...............-------------------------------------------------------------- •••••••---•----=---•-•----•----•---•---•---••------------•---••-•--------------•---
W
UNature of Repairs or Alterations—Answer when applicable � � ; l.Q. 1
i �
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bCetV issued by the lard f alth.
Signed
,v Jvi
�I
Date
Application Approved BY ,= (.'.. --•-------
/ Date
Application Disapproved for the following reasons: ........................✓.........--•-------------------------.....-•-•-•------..............=••......----•---
•..................•---••--••------•--.............-----------•--••-----........-•••••-•-.••••.•---•--••..............------------------.••------•...--•-••----------------•...........-------------•--•-
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`t.1. ............O F..J,a. ��2. ........................... }'
ATrrtif ir�tr of f�rrnt�ltttnrr
THI IS 0 CERTIFY, That he Individual Sewage.Di osal System constructed ( ) or Repaired (i_-4
by.:........ ' ' ---•
Installer ,
at;w........ til�z ,�( :-•- =- - d •.............•-•--...--.....---•••......--•-•---••.......••-
has been installed in accordance with the provisions of A•ri I-e XI of Tl State Sanitary Code as described in the
application for Disposal P l Works Construction Permit No.7 ...�..�7-7-------------- dated.---&�-- .................
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.... v ---2 1: Inspector_. / -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.� OF , , ..............................
No.....••--- Z,7
FEr,�j..GZ):._..__.
Dinpn at Workii Tomitriirtion Vrrnt't
.. L -
Permission is hereby granted.. -- -
to Concs�truct. ( or Repair ( an Individual Sewage Disposal System
atNo-9)-s (.1 ... � .....- t�� ------------------------------------------•-----•---
S e _
as shown on the application for Disposal Works Construction Permit*No.... ......:.......Dated...%--_�.11`. `-.............
�✓ ��
Board of Health
-= v y...
DATE-•; %C
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS '
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LOCATION ' 5EW&(:GE PERMIT UO.
la
MIS &L-LER 5 1 &ME ADDRESS
Lx
bU1LDER5 tJL�A/lE ADDRESS
D®,�'E PER"VT ISSUED
D 41T-E COMPLI W ACE ISSUED : - - -
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1
y JOSEPH P. MACOMBER & SON, INC.
BOX 66 - CENTERVILLE, MASS. 02632 - PHONE 775.6412 7753338
Board of Health
Town of Barnstable
August 25, 1976
Gentlemen:
Subject : Ronald Dudley, 215 Fourth Avenue, West Hyannisport, Mass ,
Permit #377. Repair.
In regards to the new Septic System installed by Joseph P. Mac-
omber & Son, Inc . , at the above. address , This is part of a cottage
development, granted we believe by the Board of Survey (Selectmen) .
The requirements were and still exist for 5' setback from property
lines, this includes dewellings . Ath this address stated above they
do not have cellars or crawl space area' s just room to shut off water.
We removed old cesspools that were running over, and replaced them
.with 1000 gallon septic tank and 2-1000 gallon leaching pits, on this
property at the rear of the building to correspond with abutter' s
cesspool. In doing this we felt with our measurement ' s and train of.
thought that we were protecting their boundri.es and existing properties .
Examing the possibilities of using the fromt of the building facing
Fourth Avenue,- we had two water- lines on the West and gas line on
the East. Owners line is 5' off property line and abutters line is
approximately 72' .
This new Septic System is in same .locati.on as old cesspool. We
are enclosing sketch of plot plan .showing property line as given to
us by- abutter's and location of gas and water lines ,
We leave examined article 11 and alsor, regulation of your ..Board
and feel we have complied to the best of our ablii.ty to *meet the
requirements of the law. But under these and existing circumstances it
was and is impossible to do this as we have in stalled many cess-
pools or pits in this area. Thank you.
Since ely,
Joseph P. Macomber & Son, Inc .
A SON, INC.JOSEPH P. MACO �ER IVI
BOX 66 - CENTERVILLE, MASS. 02632 - PHONE 775-U12 775-3&V
EST 1 YT) wM.)s ()R l
. P
®3 J Wo) .pyvp�er- y )..I roe
ro
94
HOUS)�
WEST CR5�
Mstc LI) e beltweer) ,
GP,s�+ U�t�T�eY 1 ivves '
-AO t4
POU.RTH A)) T)VU F-
r
UNITED STATES POSTAL SE _ .��•� '
OFFICIAL BUSINESS �� �� 1 PENALL.K.,
USE TO AV
SENDER INSTRUCTI F,M OF' S G
I976ppp
Print your name,address,and ZIP Code in t e'S'pgce �
• Complete items 1, 2, and 3 on rev d'ei.
• Moisten gummed ends and attach to back of article.
RETURN
TO
Town of Barnstable
Board of Health
P . 0. Box 534 A e`
r,
HYANNIS, MASS. 02601 .'
I
I
H0 SENDER: Complete items 1.2,and 3.
o Add your address in the "RETURN TO" space on
3 reverse.'
o .1. The follgv,,ung service is requested (check one).
Ljh6w to whornb and date delivered...____.____ 150
ET Show to whom, date, & address of delivery.. 350
RESTRICTED DELIVERY.
Show to whom and date delivered............. 65Q
RESTRICTED DELIVERY.
Show to whom, date, and address of delivery 850
1
A 2. ARTICLE ADDRESSED TO:
Mr. Joseph Macomber
i 24 Main Street
A
m Centerville, Mass'.
m 3. ARTICLE DESCRIPTION:
REGISTERED NO. CERTIFIED NO. INSURED-NO.
1607940
y (Always obtain signature of addressee or agent)
zI have received the article described above.
rn SIGNATURE ❑ Addressee ❑ Authorized agent
C a.
m DATE OF D LIVER POSTMARK
O
C 5. ADD S (Co plete only if requested) C'7�►
A r
"t
6. UNABLE TO DELIVER BECAUSE: CLERK'S
G INITIALS
r
{r GPO:1975--0-SN-067
August 26, 1976
Mr. Joseph Macorber
24 Main Street
Centerville, Massaehusetto 02632
NOTXCE TO CORRECT VIOLATION OF TITLE 3 MWIRONXIXTAL
_LUALITY MnMIRRM, IQULZRONMRSTAL CODE.
The sewage system installed by you at 215 Fourth Avenue,
Kest Hya aisport,, vain Inspected for issuance of a
certificate of eoaplinnce in accordance with lRBtltM TIAN
of the above nentioned State Code by Mr. 3dwir—d J*WdR t
Oft August 23,E 1976. Thy! following Violatiaxs were femd t �
REGDLATI 3. One .leaching pit was installed fifteen
and on* half 3 OWS feat from the dwelling.
The other leaching pit was installed 12h feet iron the
dwelling,.
The application signed by you and dated August 18, 1976*
stated that you agreed to install the systea in acca;rdanoe
` with the State Sanitary Code.
You are directed to correct the above violations within
three (3) days of receipt of this order. Failure to di
so could result in revocation of your **wage installers
permit.
You may request a hearing before the Board of Health if
written petition requesting same is received $#ven (7) days
after the date order served.
Any person who fails to comply with any order pursuant to
the state Sanitary Code it subljaelF to a fine of not nor*
than $500. Each days falluTO to Comply with an order shall
constitute a separator violation.
PER ORDER OF THE BOARD OF HEALTH
JOHN M. RELLY
DIRECTOR OP pUSLIC HEALTH
JMK�jg
UNITED, STATES POSTAL SE
OFFICIAL BUSINESS A i"'; TIE`
PENALTY-FOR PR(YA
' USE TO AVOU)-PAYMEf+T--. r
SENDER INSTRUCTI Nt f`''`` OF PO�ST},ttF�30Q �.m tit er
Print your name,address,and ZIP Code in ftte:Space bvIoW..
• Complete items 1, 2, and 3 on rever33e'side: `tea
• Moisten gummed ends and attach to back of article.
RETURN
TO
Town of Barnstable
I
Board of Health
P . 0. Box 534
HYANNIS MA 02601
- I
H SENDER: Complete items I.Z.and 3.
o -Add your address in the "RETURN TO" space on
3 __ ,reverse.
0 1. The following service is requested (check one).
[� Show.to whom and date delivered............ 150
❑ Show to whom, date, & address of delivery.. 350
RESTRICTED DELIVERY.
Show to whom and date delivered............. 650
RESTRICTED DELIVERY.
Show to whom, date, and address of delivery 850
2. ARTICLE ADDRESSED TO:
AJoseph P . Macomber & .Son; Inc.
Z P. 0. Box 66
Centerville, Mass . 02632
m 3. ARTICLE DESCRIPTION:
REGISTERED NO. CERTIFIED NO. i INSURED NO.
A 607945
m
O
1 (Always obtain signature of addressee or agent)
rn I have received the article described above.
C SIGNATURE ❑ Addressee ❑ Authorized agent
Z L
N
C q,
m D Tf�QF QELIVE0 POSTMARK
p 5. ADDR S (Complete only it requested)
nni .
6. UNABLE TO DELIVER BECAUSE: `CLERK'S
INITIALS
IC
r
{r GPO:1975—o 58e-047
c
August 31� 1976 `
Joseph P# Macombetr. & son, Inc,
P"O.BOX 66 _
Centerviilo, Mass* d2632
E ND WARNING POR V Oi,ATION OF_ TITLE S. TAT : ENV TROYMENTAL
QUALITY.-ENGINEERIN2 CODE
You are officially warned concerning the installation of a
septiO System at the residence of Mr, Ronald Dudley,
215 Fourth Avenue, `lost Hyannisport. This 'system did not
confrom to St4te and Town regulations. Any Further violations
will result iA suSpension. eta revocation of your Installer's
F ermit.
You are reminded that a vari.ence is required from the Hoard
•cif Health in all 66ance . when you ..deviate from the Code.
Prior to-the issuance of a Compliance Certificate, we must
receive a setter from the owner of the property stating
that he understands the system does not-meet the Code and
has no obJections.
TOWN OF BARNSTABLE EOARD'OF HEALTH.
Robert L. Chi lde, Cha xne
LUC
A* Jan Es
Gei4 d W �ard4, M.D.
r
October 22, 1916
Mr. Joseph P« Macomber
Joseph F, Macomber & Son,, Znei
Box 66
Centerville, Massachusetts
Dean` Mr, Macomber;
Vou received a warning on August 31, 3976,, concerning the fins
etallation of a septic system for Mr. RbnaI4 Dudley., 21.5
Fourth Avenue.+ Hy�annfsporto This system did not meet. the rep-
quiremOnts of Title 5.0, Of the State Environmental Code,
we directed you to obtain a letter from the owner that he has
no objection to the fact that this system dries not Meet; the
cage, This is necessary in order for us to issue a compliance
certificate*
Please be advised that until this setter Is obtained, we will
not issue you any further sewage disposal construction permits.
Very truly your$
Robert L ids* Chair Waif
Ann J Eshbaugh
/,t AL �
G add W# Hazard, . D,
HOARD OF HEALTH
TOWN OF BARNSTABLE
JMK/mm -
N
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s
Tamita Realty Trust
50 ' Spellman Road
Westwood, Mass 02090
Anne V. Vegnani , trustee
October 27th, 1976
Mr. John -Kelly
Public Health Department_
397 Main Street
Hyannis, Mass 02601
ftE: 215 Fourth Ave
W. Hyannisport, Mass.
----------------------
Dear Mr. Kelly:
After speaking with a lady in the Board of Health Dept. , I
was advised to write you a letter stating the following: " We have
no objection to the system that MACOMBER has installed at 215 Fourth
Street, West Hyannisport, Massachusetts and we do realize that this
system does not meet with the sanitary code."
Trusting the above will assist you in this matter, I remain
Very truly' yours,
Anne V. regznan�i , trustee for
TAMITA REALTY TRUST
ec: , Macomber
I
I
UNITED STATES POS vRV
OFFICIAL BUSTo OCT26;
F'IN P
USE.7�.�it�,1R t�
SENDER INSTRU
I Print your name,address,and ZIP Code in the space below. r.=.
• Complete items 1, 2, and 3 on reverse side. ^-_'
• Moisten gummed ends and attach to back of article.
RETURN
j TO
I
I
I
Board of Health
Town of Barnstable
f P. 0. Box 534
HYANNIS MA 02601
I
I
I
H 0 SENDER: Complete items 1,2,and 3. , �
c Add your address in the "RETURNATW' space on
3 -reverse.
m 1.'The following service is requested (check one). 1
® Show to whom and date deliverdd9.AA A.' •154
0 Show*io whom, date, &address of delivery-. 354
RESTRICTED. DELIVERY. t t t 1 I
Show to whom and date delivered............. 650
RESTRICTED DELIVERY.
Show to whom, date, and address of delivery 850
2. ARTICLE ADDRESSED TO:
c Mr. Joseph P . Macomber` • '
i Joseph P . Macomber & Sonf11nc
Box 66,Centerville,Ma.02632
m 3. ARTICLE DESCRIPTION:
REGISTERED NO. CERTIFIED NO. INSURED NO.
m I 607964I
M
1 (Always obtain signature of addressee or agent)
mm I have received the article described above.
C SIGNATlJf2E ❑ Ad�sse ❑ Authorized agent
H -
2
4.
A DATE OF DELIVERY POSTMARK
m
0
p 5. ADDRESS (Complete only if reques d)
m 6. UNABLE TO DELIVER BECAUSE: > CLERK:S
� dl
r
'yr GPO:I 47