HomeMy WebLinkAbout0022 FRESH HOLES ROAD - Health -- -
22- Fresh Holes Rd
aka 22-24 Fresh Holes Rd
292-183 Hyannis
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Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1. Property Information:
forms on the „
.computer,use 22-24 Fresh Holes Road vv`tl
only the tab key Property Address
to move your Today Real Estate
cursor-do not Owner's Name
use the return
key. 1533 Falmouth Road
Owner's Address
Centerville MA 02632
City/town State Zip Code
Date of Inspection: Date 08
Date
2. Inspector:
MR. ROBERT A. DRAKE
Name of Inspector
KCJ ENGINEERING
Company Name
66 GREENVILLE DRIVE
Company Address
FORESTDALE MA 02644
City/rown State Zip Code
508-477-5048
Telephone Number
Certification Statement: } —'
I certify that I have personally inspected the sewage disposal system at this addres land that-the --
information
reported below is true, accurate and complete as of the time of the inspection.Tlaeinspection
was performed based on my training and experience in the proper function and mainenanceof on-srte
sewage disposal systems. I am a DEP approved system inspector pursuant t 1 3340 0
Title 5(310 CMR 15.000).The system: N F Mgssac
rn
® Passes ❑ Conditionally Passes BERT A. �G
g DRAKE
ElNeeds Further Evaluation by the Local Approving Authority 2 CIVIL
v Nc.41642 O
Inspector's Signature Date `FSIpNr�,_E��\
The system inspector shall submit a copy of this inspection report to the Approvi uthoriry(Board
04
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
Citylrown State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of Inspection
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:
All components appear to be structurally sound and working properly. No signs of leakage or
blockages. SAS located under parking lot. Board of Health approved prior title 5 inspection by
Macomber on 6/21/00 of SAS location with no vent pipe.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined(Y, N, ND)in the❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or.the septic tank(whether metal or not)is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
22-24 Fresh Holes R6ad-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
Cityfrown State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of Inspection
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
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
Pore 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
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached
to this form.
3. Other:
22-24 Fresh Holes Road-T51NSP1.DOC.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
City/Town State ZipCode
Today Real Estate 01/18/08
Owner's Name Date of Inspection
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than'/Z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to dogged 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure criteria are triggered.A copy of
the analysis must be attached to this form.]
Yes No
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
City/Town State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of.lnspection
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
E] ❑ 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.
I
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 6of16
Commonwealth of Massachusetts
--- - Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
4
B. Checklist
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 01/18/08
Owner's Name Dated Inspection
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:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
City/rown State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 208 gpd
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: a couple of
months ago
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Duplex built in 1945. System was upgraded in 1996. Town Of Barnstable Health Department records.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9of16
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: approx. 2.5'
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints appear to be structurally sound, no signs of leakage.
Septic Tank(locate on site plan):
Depth below grade: 2.0
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Cover at grade. Top of Tank approx. 2' below grade. Tank appears to be structurally sound and
functioining properly.
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 1,500 Gallon
Sludge depth: approx. 6-inches
Distance from top of sludge to bottom of outlet tee or baffle approx. 28-inches
Scum thickness approx. 4 inch
Distance from top of scum to top of outlet tee or baffle approx. 8-inches
Distance from bottom of scum to bottom of outlet tee or baffle approx. 12-inches to pipe invert
How were dimensions determined? MEASURED IN FIELD
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 01/18/08
Owner's Name Dated Inspection .
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
All components appear to be structurally sound and working properly.The existing PVC tees are in
place and appear to be in good working condition.Water level at invert of outlet pipe.
Grease Trap(locate on site plan):
Depth below grade: N/A
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
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: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of Inspection
Tight or Holding Tank(cont.)
Dimensions: N/A
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert Is at outlet pipe
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.):
Appears to be sound and working propoerly. No signs of backups.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12of16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
City/rown State Zip Code
Today Real Estate 01/18/08
Owner's Name _ Date of Inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 4-500 gallon
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
I
❑ 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.):
Existing SAS field is below parking lot with no vent pipe. Previous Title 5 report on 6/21/00 by
Macomber, BOH approved.
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 13 of 16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
Citylrown State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of Inspection
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration N/A
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
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: N/A
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of p.onding, condition of vegetation,
etc.):
22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14of16
I
Commonwealth of Massachusetts
`title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
City/rown State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of Inspection
Sketch Of Sewage Disposal System: Provide a Sketch of the sewage disposal system including ties
to at least two permanent reference landmarks.or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
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22-24 Fresh Holes Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 15of16
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
22-24 Fresh Holes Road
Property Address
Hyannis MA 02601
Cityfrown State Zip Code
Today Real Estate 01/18/08
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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:
Barnstable GIS Groundwater Maps indicate high groundwater elevation is at approx. =27', GIS
Contour Maps indicate ground elevation is at approx. 50', Approximately 23'of separation between
ground and high ground water. Approximately 10' +separation between bottom of SAS and HGW.
22-24 Fresh Holes Road-T51NSP1.DOC.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 16of16
I
Town of Barnstable
Op 1HE Tp�
Regulatory Services
,AR,,S,,,B Thomas F. Geiler,Director
ATED �p Public Health .Division.
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private•inspector who is certified
by the State of,Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system.in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report. ,
In addition, by receiving this report the Town of Barnstable Health'Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
Certified Mail#7003 1680 0004 5458 4777
°FSH A Town of Barnstable
Regulatory Services
• nnEuvs-raeLE.
9 MASS. g, Thomas F. Geiler, Director
i639. �0
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
June 28, 2007
Paulo Rodrigues
P.O. Box 541
W. Harwich, MA 02671
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 24Fresh Holes Road Hyannis was inspected
on June 21, 2007 by Timothy O'Connell, Health Inspector for the Town of Barnstable.
This inspection was conducted on the basis of a complaint received by the Town of
Barnstable. '
The following violations of the State Sanitary Code were observed:
105 CMR 410.100 A 2 -Kitchen Facilities. Pilot light on stove goes off on its own
)O g g ,
causing gas to leak.
105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements. y
Carpet in need of replacement; window does not open; toilet leaks at supply line.
The following violations of the Town of Barnstable Code were observed:
1§ 70-4—Certificate of.Registration. Property is not registered with Town of
Barnstable Health Department.
QAOrder letters\Housing violations\24 Fresh Holes Road.doc
You are directed to correct the violations listed above within thirty (30) days
of your receipt of this notice by repairing pilot light on stove so it works properly;
by replacing carpet; by repairing or replacing window so it opens and shuts with
ease; by fixing toilet so it doesn't leak; by registering rental property with Town of
Barnstable by filling out application and submitting appropriate fee.
i
i
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 OARD OF HEALTH
omas A. McKean, ,CHO
Director of Public Health
Town of Barnstable
Cc: Timothy O'Connell, Health Inspector
QAOrder letters\Housing violations\24 Fresh Holes Road.doc
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Request ID: 21034 Created: 6/11/2007 11:39:44 AM
Status: Assigned To Staff Assigned To: O'Connell,Timothy
Health Office
Anonymous: No Request Category: Chapter II : Housing
Substandard edit
Estimated 6/13/2007 Change Estimated " June 2007 Jul
Completion Completion Date:
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Created By: Fontaine,Tina Priority: Medium edit
Health Office
Citation Numbers: edit
Requestor Information
Requestor
Request Parcel Number
This rental place has water Map: 000 ; Block: 000 I Lot: 000 i
leaking from bathroom. A dirty carpet
that the landlord said he would Parcel Lookup
replace when he moved in but hasn't
done so. Also shingles are all over the
place outside.
http://issgl2/lntemalWRSAVRequest.aspx?ID=21034 6/13/2007
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http://issgl2/lntemalWRS/V Request.aspx?ID=21034 6/13/2007
i
FORM 30 CkW HOBBSB WARREN'M THE COMMONWEALTH OF MASSACHUSETTS
BOA D O LTH
ciT Rown
b r — DIEPAFITIq V �
( l 6
ADDRESS
TELEPHONE �Q
Address _ Occupant_ `-0 t Yam%
Floor Apartment No. No.of Occupants ���
No.of Habitable Rooms_No.Sleeping Rooms_;
No.dwelling or rooming units_ No.Storips
Name and address of owner �1
i► Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling: Q Svc
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line: `
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
11110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Si
tov �
Bathing,Toilet Facil. nt., 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: IV
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 REPORTASIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIESOFE O JURY.,
INSPECTOR TITLE
• A.
DATE e_6 TIME 6
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
e
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health,or safety and well-being of a'person or persons occupying the premises.This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such+violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in'quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
F }
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
I 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 oir 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.
r -
Iwo
(4r4o�'�
0 ,000
COMMONWEALTH OF MASACHUSETE°T1k?ee
EXECUTIVE OFFICE OF ENVIRONMENTDEPARTMENT OF ENVIRONMENTAL PROTE
ONE WINTER STREET BOSTON MA 02108(617)292-3500 e
TRUDY COXE
Secretary
ARGEO PAULCELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 22& 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner JEFF LYON
Address of Owner: BOX 611 HYANNISPORT MA.02647
Date of Inspection: 6/23/00
Name of Inspector: JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 608-564-7270
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 in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes
_ Conditionally Passes
_ Needs Further Evaluation y the Local Approving Authority
Fails
Inspector's Signature: Date:7/3100
The System Inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If t 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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
i
revised 9/2198 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 22& 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner JEFF LYON
Date of Inspection: 6/23/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination In all Instances.If"not determined",explain why not.
nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance
attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,
whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The
system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health.
nta 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,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction Is removed
_distribution box is levelled or replaced
n/a 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
i.
i
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 22& 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner JEFF LYON
Date of Inspection: 6/23/00
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 the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is v:ithin a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 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 5 ppm,Method used to determine distance n!a (approximation not valid).
3) OTHER
n/a
revised 9/2/98 Page 3 of 11
'r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
I
Property Address: 22& 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner JEFF LYON
Date of Inspection: 6/23/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
- X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
- X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
- X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
- X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Q.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
- X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
- X 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.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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:
Yes No
- X the system is within 400 feet,of a surface drinking water supply
X the system is within 200 fe&of-a tributary to a surface drinking water supply
X 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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further Information. '
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 22 & 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner: JEFF LYON
Date of Inspection: 6/23/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.
Large volumes of water have not been introduced into the system recently or as part of this inspection.
X _ As built plans have been obtained and examined.Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X _ All system components,excluding the Soil Absorption System,have been located on the site.
X _ The 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.The size and location of the Soil Absorption System on the site has been
determined based on:
X _ Existing information,For example,Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
.An
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 22& 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner JEFF LYON
Date of Inspection: 6/23/00
FLOW CONDITIONS
RESIDENTIAL
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual):
Total DESIGN flow: 440 gpd
Number of current residents:7
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIALCOMMFRCIAI/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping:n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Privy
_ Shared system(yes or no)(if yes.attach previous inspection records,if any)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1996-PERMIT 96488
swag@ odor=d@WIM wh@n arriving at th@§il@ (y@@ or no) NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 22& 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner JEFF LYON
Date of Inspection: 6/23/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 12"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction.line: n/a
Diameter: 4"
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 3"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 160OG L 10'6"H 5'6"W 5'8
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIFE.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n/a
4 t,.
revised 9/2/98 Page 7 of 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 22& 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner JEFF LYON
Date of Inspection: 6/23/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,Inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2198 Page 8 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 22& 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner JEFF LYON
Date of Inspection: 6123/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(n/a)n/a
leaching chambers,number: (4)CULTEC CHAMBERS
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE SAS APPEAR TO BE FUNCTIONING PROPERLY.THE SYSTEM SHOWS NO SIGNS OF FAILURE.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 22& 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner JEFF LYON
Date of Inspection: 6/23/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
•� e
�r
J
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 22& 24 FRESH HOLES RD HYANNIS, MA 02601 M292 P18
Name of Owner JEFF LYON
Date of Inspection: 6123/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
UGSS MAPS AND CHARTS-10+FEET
revised 9/2198 Page 11 of 11
Commonweafth of Mossachusetts _
Executtve Office-of ENronmentaf Affairs. John-Grad -
_ -D.E.P. Title V Septic Inspector
Department of s - P.O. Box2119
EnvironMental Protection Teaticke T,516,
- rf50 •k6 - 813 --
SUBSURFACE SEWAGE DISPOSAL D S I SYSTEM INSPECTION FORM
CERTIFICATION - _PART A- S EP 1 G 1�6`.
Property Address: 22.24 Freshholes Rd.Hyannis
_ . Address of Owner.
Date of Inspection:91519g (If different) -000t
Name of Inspectok:John Graci - Dav_IdJarort
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 in the proper function and
maintenance of on-site sewage disposal systems. The system:
ASSE SSORS MAP No: g
Passes PARCELNO:.
_ Conditionally Passes
Needs Further Evaluation 8y the Local Approving Authority ��
X Fails �,GL
Inspector's Signature: J Date: 915198
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
_I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,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 substantial infiltration or exfiltration,or tank failure is
imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised IIn5195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
1
i
-- i
SUBSURFACE SEWAGE DISPOSAL--SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
-Property.Address: 22.24 Freshholes Rd.Hyannis
Owner: DavidJarofr
Date of Inspection:915196
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced -
obstruction is removed
distribution box is leveled 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 -
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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has aseptic 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 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an 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
cesspool.
X SAS is in hydraulic failure.
(revised 11115195)
2
;e'�evri'9 °?� r ' � -4 � r w •.�rA.ge r+� s"'y�C N`3t.'�<
SUBSURFACE_SEWAGE DISPOSAL SYSTEM INSPECTIONFORM x
PART,A
CERTIFICATION (continued),.
Property Address: 22.24 F.reshholes Rd.Hyannis
Owner: - DavidJarofr - f'
Date of Inspection:9151962.
D] SYSTEM FAILS(continued) - +
'Static liquid level in the distribution box above outlet due 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).
Numbers 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 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. 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.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to'the criteria:
_ The system serves a facility with a design flow of 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)or a mapped Zone.II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility 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 11115195)
3
j .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
-Property Address: 22.24 Freshholes Rd.Hyannis _
OWner: DeVld Adroir
Date of Inspection:915196 _
Check if the following have been done:
_X Pumping information was requested of the owner,occupant, and Board of Health.
_ X-None of the system components have.been pumped for,at least two weeks'and the.and,the system has been receiving normal '
flow rates during that period: Large volumes of water have not been introduced into the system recently or as part of this
inspection. . -
taAs built plans have been obtained and examined. Note if they are not available with N/A
X The facility or dwelling was inspected for signs of sewage back-up.
X` The,system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs.of breakout.
X All system components, excluding the Soil Absorption System, have been located on the site.
X The septic tank manholes were'uncovered, opened, and the interior of the septic tank was inspected
for condition ofbaffles or tees,material of construction,dimensions;depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by,non-intrusive methods.
X The facility owner(and occupants, if differen
Surface Disposal System. t from owner)were provided with information on the proper maintenance of Sub'
(revised 11115195)
' 4 .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM " {
PART C.
fSYSTEM INFORMATION '
Property Address:'22-24 Freshholes Rd.Hyannis
Owner: -DavidJarolT _
Date of Inspections 915196 _
FLOW CONDITIONS. . -
RESIDENTIAL:-
Design flow: u gallons
Number.of.bedrooms: 4 a .... -.
Number of-current residents: a
Garbage grinder(yes or no): No
Laundry connected to"system(yes-or no): Yes iw -
Seasonal use(yes or no): No -
Water meter readings,if available: nla -
Last date of occupancy:.nta
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the,Title 5 system: (yes or no)No
Water meter readings,if ayailable: Na
Last'date of occupancy: nla
OTHER: (Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information;
System was pumped B Months ago by Bortolotti
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: nta
TYPE OF SYSTEM
Septic tank/distribution box/soil.absorptions system
X Single cesspool.
X 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 information:
1950 -
Sewage.odors detected when arriving at the site: (yes.or no) No
(revised.11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -
PART C
-SYSTEM INFORMATION (continued)
Property Address: 22.24 Freshholes Rd.Hyannis
Owner: DavidJaroA
Date of Inspect!on:915196
SEPTIC TANK:_
(locate on site plan) -
Depth below grade: rda
Material of con struction:_concreate_metal FRP_other(explain)
Dimensions: rda. -
Sludge depth:nla
Distance from top of sludge to bottom of outlet tee or baffle: nra
Scum thickness:n1a
Distance from-top of scum to top of outlet tee or baffle:Na
Distance form bottom of scum to bottom of outlet tee or baffle: n1a
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage, etc.)
n1a
GREASE TRAP:_
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: nta
Scum thickness:n1a
Distance.from top of scum to top of outleftee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
nla
(revised 11115195)
6
arf ... � .�,mod'• i1'�q, �, y Y �.i a � e j � y , � �
� �"_
Iv '— `''• '- t R.. 4, x¢ .r Fr
-SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM =
I _ PART C
SYSTEM INFORMATION (continued) - -
Property Address: 22.24 Freshholes Rd.Hyannis -
Owner: DavidJaroA - - -
Date of Inspection:915196 — --- -
TIGHT OR HOLDING TANK: -
(locate on site plan) _
-Depth below grade:rVa _
Material of construction:_concrete_metal_FRP_other(explain) — -
Dimensions: Na
Capacity: -n1a gallons -
Design flow: n1a gallons/day
Alarm level: Na
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n1a
(revised 11115195)
I 7
r.•. ..ems'k�� �' � t - ', X+.,:,$'4'a t-... -
•
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM -
' ::'PART C
.SYSTEM INFORMATION (continued)_
.:
Property Address: 22.24"Freshholes Rd.Hyannis -
Owner: DavidJarofr. '.
Date of Inspection:915196.
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,.if possible; excavation not required; but maybe approximated by,non-intrusive methods),
If not,determined to be present, explain: -
Na _
Type: .
leaching pits, number: r1a.
"leaching chambers,number:nla -
leaching galleries, number: n1a
leaching trenches,number,length nia
leaching fields, number. dimensions:nla
overflow cesspool, number:5x5 block'
Comments:(note condition of soil, signs of hydraulic:failure, level of ponding„condition-of vegetation, etc.)
Overflow is in hydraulic failure
CESSPOOLS:.x .
(locate on site plan)
Number and configuration: one
Depth-top of liquid to inlet invert: over
Depth of solids layer: 4'
Depth of scum layer: u
Dimensions of cesspool: 4x5
Materials of construction: block
Indication of groundwater: none
inflow(cesspool must be pumped as part of inspection)
n1a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition-of vegetation, etc.)
System is in hydraulic failure
PRIVY:_
(locate on site plan)
Materials of construction: n1a Dimensions: n/a
Depth of solids: Na
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PrivyComments _
(revised 11115195)
74
SUBSURFACE SEWAGE DISPOSAL- SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
"Property Address: 22.24 Freshhales Rd.Hyannis — —
Owner: DaWdJarort _
Date of-Inspection:915198
SKETCH OF.SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' - �-
I
eats �o Get
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised I ill 5/95)
9
TOWN OF BARNSTABLE
L(aCATION ;Z A :Z / ,c-S & 'AdSEWAGE #
VILLAGE ASSESSOR'S MAP & LOTQ&,�M
INSTALLER'S NAME&PHONE NO. 2'7 ,<— S e7 `? L
SEPTIC TANK CAPACITY 1-r G p
LEACHING FACILITY: (type) �� (S )T (size) /6 3 0 4 7- G G
NO.OFBEDROOMS �/
BUILDER OR OWNER 4e a ^L 5
PERMIT DATE: (�,-' COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bot of Leaching Facility Feet
Private Water Supply Well and Leaching F i 'ty (If any wells exist
on site or within 200 feet of leachin acility) Feet
Edge of Wetland and Leaching Fac' ' (If any wetlands exist
within 300 feet of leaching fa ility) Feet
Furnished by
r
i
� r
Cif
i
O�
(d Fee $40 . 0Q.
No.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS','°
0(ppYicatton for ;Migpool *pgtem Congtruction Vermft
Application is hereby made for a Permit to Construct( )or Repair(X )an On-site Sewage Disposal'System at:
Location Address or Lot No. Owner's Name,Address and Tel.No. 7 71 —2 0 0 8
22-24 Fgsh Holes Rd, HyANNIS Jeff Lyons
Assessor's Map arcel
724 Main Street, Hyannis, MA 02601
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
Wm.E.RobinsonSr. , Septic Svc.
P.O.Box 1089 , Centerville MA 0263
Type of Building: Duplex
Dwelling No.of Bedrooms 2 each Garbage Grinder(n
Other Type of Building No.of Persons o) Showers( Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil gravel
Nature of Repairs or Alterations(Answer when applicable) Fill in old cesspool,
Install Title 5 system-1500 gal. tank, D—box and 4 heavy duty,high—
capacity, stonepacked Cultex #330 infiltrators.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B and of He
Signed e:yr Date 2^vz `/ 4
Application Approved by .. - _ Date CZ r ,
Application Disapproved for the following reasons
Permit No. /�p� Date Issued
No. Fee
40.00
THE COMMONWEALTH OF M SSACHUSETTS a
- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for Mi5po0ar *pMem Con!gtructioit permit
Application is hereby made for a Permit to Construct( )or Repair(X )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No. 7 71 —2 0 0 8
22-24 Fresh Holes Rd, HyANNIS Jeff Lyons
Assessor's Map/Parcel "
724 Main Street, Hyannis, MA 02601
Installer's Name, ddress,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
Wm.E.R , insonSr. , Septic Svc.
P.O.Box 1089, Centerville, MA 02632
Type of Building: Duplex
Dwelling No.of Bedrooms 2 each Garbage Grinder(na
Other Type of Building No. of Persons Showers( ) Cafeteria
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
r. Plan Date Number of sheets Revision Date
Title
Description of Soil gravel
Nature of Repairs or Alterations(Answer when applicable) Fill in old cesspool,
Install Title 5'"system-1500 gal. tank, D-box, and 4 heavy duty,hiah-
capacity, stonepacked Cultex #330 infiltrators.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance,of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5,of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this B and of He It
� P Y r p
i Signed /o i _ Date !^.Z 4,
Application ation Approved b �. %�f Date _
PP, PP Y � -
Application Disapproved for the follow ng reasons
p
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
Lyona BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(x )on _
by Installer Wm. E. Robinson Septic Svc.
at a2-24 Fresh Holes Rd_ Hyanni c has been constructed in accordance
with the provision of file • and the for Disposal System Constructi,n Pe t No. W iated
Date LQ _ Inspector
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
---------------------------------------
No. - Fee $4 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS
Lyons PUBLIC HEALTH DIVISION . BARNSTABLE, MASSACHUSETTS
Mizpogal *pgtem Cow5truction hermit
Permission is hereby granted to W.E.Robinson Sr. r Sent-i c- Sry-
to construct( )repair( )a an On-site Sewage System located at No.# q_q__24 Fresh Holes Rd. , Hyanni s
Street
and as described in the above Application for Disposal System Construction Permit. - 6
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
Date: Approved by ci Board of Health
A
i
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)-
. I wm.E.Robinson, s r. , hereby certify that the application for disposal works
construction permit signed by me dated 9-2 4-9 6 , concerning the
property located at 22-24 Fresh Holes. Rd. , Hyannis , MAneets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
r ,
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED: Z�V _
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].
P _
. ,
4�
_ t
_ �� 1 - _ _
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_ 1
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4
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_ — y
TOWN OF BARNSTABLE 7
OFFICE OF
11 dAH IL $ i BOARD OF HEALTH
•tea ,�
a639• ��� 367 MAW STREET
0 G PY k'
HYANNIS. MASS. 02601 i
June 291 1981 �3 a
Elizabeth C. Jones, Trustee
Quaker Village Assn.
c/o Dolben Inc. ,Agents
a_0 Court Street
'3' S
Boston, MA.
i
NOTICE TO ABATE A VIOLATION- .OF. .STATE SHITARY
RD LONE CHAPTER II
MINIMUM STANDAS OF FITNESS FOR HUMAN
The property owned by. you at 22 Fresh Holes Road, . Hyannis , was inspec-
ted on June 24,- 1981 , by Ronald Gifford, Health 'Inspector for ...the Town
of Barnstable, because of a complaint ,by the tenant, Joyce Willis: ;
The following violations of State Sanitary Code, Chapter II, 105 CMR
410.000 were observed:
REGULATION 410. 351 (A) : "lectr.ic outlet in living room on dividing $
apartment ino erable. ht switch in rear try way de
wall of p f Switch cover plate i athroom missing.
fective - doesn' t turn off.
Drain water from handbasin backs up into bathtub. Drain in bathtub
very slow.
REGULATION 410.500: Caulk at bathtub deteriorating allowing mold
buildup and making cleaning difficult: ° Putty deteriorating in
windows - white bedroom. ;
REGULATION 410.501 : itc hen window and window in �ue bedroom will
not stay open - held open by sticks.
REGULATION 410. 551 : &19er--_s creep on rear window - white bedroom.
You are directed to correct all•.violations within seven (7) days of re-
E ceipt o-f•this notice. '
You may request a hearing before the Board of Health if written petition
requesting same is received within seven (7) days after "the `date order. I
4
served. i
Non-compliance could result in a fine of up to $500. Each day' s failure
tc comply with an order shall constitute '.a separate violation.
��
PER ORDER OF THE BOARD OF HEALTH .71
Ji n M. e Y
Director of Public Health
JMK/mm
cc: Mr.Grover , Martin
Ms. Joyce Willis
f '
TOWN OF BARNSTABLE
OFFICE OF
i BARNMUL i
9 rasa BOARD OF HEALTH
�pA 1639. `0m 367 MAIN STREET
f
�NA k.
HYANNIS, MASS. 02601
July 7, 1981
Mr. Grover Martin
3 Hiramar Drive
Hyannis,. Ma.
Re: --22 Fresh Holes Road, Hyannis-
Dear Mr. Martin:
We are in receipt of your petition 'on behalf of Elizabeth C.
Jones, Trustee for Quaker Village Association, requesting a
hearing in regard to our letter of. June 29 , 1981.
The hearing has been scheduled for 4: 30 P.M. , on Tuesday,
July 21, 1981, in the Board of Health office, 367 Main Street,
Hyannis.
Due to the length 'of time before the hearing, we would expect
all violations would be corrected by that .date.
Very. truly .yours, ,
Y
jh
ector of Pu. is Health
JMK/mm
cc: Ms. Joyce Willis
Elizabeth C. Jones,Trustee, Quaker Village Assn.
I
UNITED STATES POSTAL SERVICE
OFFICIAL BUSINESS
PENALTY FOR PRIVATE
SENDER INSTRUCTIONS USE TO AVOIp PAYMENT
Print your name,address,and ZIP Code In the space below. OF POSTAGE.ssooUALMAIL
• Complete items 1,2,and 3 on the reverse. I e
• Attach to front of article if space permits,
otherwise affix to back of article.
• Endorse vticla"Return Receipt Requested
kaient to number.
RETURN
TO
BOARD OF .HEALTH
(Name of Sender)
TOWN OF BARNSTABLE
P. 0. Box 534
(Street or P.O.Banc)
HYANNIS MA 02601
(City,State,and ZdP Code
r h e
®SENDER: Complete items 1,2,and 3.
0 , , Add your address In the"RETURN To an
reverse. t
1. The following service is requested(check one.) { s I t
X}ER Show to whom and date delivered............ S
❑ Show to whom,date and address of delivery..._g
❑ RESTRICTED DELIVERY
Show to whom and date delivered............_a
❑ RESTRICTED DELIVERY.
Show to whom date,and address of delivery.$
(CONSULT POSTMASTER FOR FEES)
Y
2. ARTICLE ADDRESSED TO:
m Elizabeth C.Jones,Trustee
c Quaker Village Assn.
i c/o Dolben,Inc.-40 Court St.
3. ARTICLE DESCRIPTIoN: 021C8
m REGISTERED NO. �CERTIFIEOWO. iNOUR£D NO.
i I
m 0019870 I
m
0 (Always obtain signature of a;dreme or agent)
sA
'I I have received the article described above.
m
m SIGNATURE ClAddess.. 0Authodzed agent
0
a.
M DAT.EEO.FFDELIVER POSTMARK
D �-J; / CO
O S. ADDRESS(Comptels only N epuespd) 1
m ? JINN
m 6. UNABLE TO DELIVER BECAUSE:
. *'GPO:1976300-459
C0*1HETO� TOWN OF BARNSTABLE (COPY
� OFFICE OF'
i BaBH9TeBi,E, :NAM BOARD OF HEALTH
q p�
0639 367 MAIN STREET
pgAY
HYANNIS, MASS. 02601
June 29, 1981
Elizabeth C. Jones, Trustee
Quaker Village Assn.
c/o Dolben Inc. ,Agents
40 Court Street
Boston, MA.
NOTICE TO ABATE A VLOLATTON. .OF. .STATE .SANITARY.. .CODE , CHAPTER II
MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
The property owned by you at 22 Fresh Holes Road, . Hyannis, was. inspec-
'ted on "June 24,, 1981, by Ronald Gifford, Health *Inspector for the Town
of Barnstable, because of a complaint -by -the* tenant; Joyce Willis.
The following violations of State Sanitary Code, Chapter I'I, 105 CMR
410.000 were observed:
REGULATION 410. 351 (A) : Electrical outlet in living room on dividing
wall of apartment inoperable. Light switch in rear entry way de-
fective - .doesn' t turn off. Switch cover plate in bathroom missing.
Drain water from handbasin backs up into bathtub. Drain in bathtub
very slow.
REGULATION 410.500: Caulk at bathtub deteriorating allowing mold
buildup and making cleaning difficult. ' Putty deteriorating in -
windows - white bedroom.
REGULATION 410.501 :' Kitchen window and window in blue bedroom will
not stay open - held open by sticks.
REGULATION 410.551 : No screen on rear window - white bedroom.-
You are directed to correct all%violations within seven . (7) days of re-
ceipt of"thi's'notice. �••
You may request a hearing before the Board of Health if written petition
requesting same is received within seven (7) days after the date order
served.
Non-compliance could result in a fine of up to $500. Each day' s failure
tb comply with an order shall constitute a separate violation.
PER ORDER OF. THE BOARD OF HEALTH
J n M. I ely
rector of Public Health
JMK/mm
cc: Mr.Grover � Martin
Ms. Joyce Willis
` BOARD OF HEALTH
Town of Barnstable
P.O. Box 534
Hyannis, Massachusetts 02601
This is an important legal document. It may affect your rights.
You may obtain a translation of this form at the Town Office.
ARTICLE II
STATE SANITARY CODE /
Address: . .o�._. o�_. . . . . C 2 S�j/. . . . . ./ J.L. �. . . .�. D,. . . . . / )'J9 A/APS. . No. Occupants . . . . . . . . . . . .
Occupant: . . . . . . . . . . .A-) . . . . . . . . . . . . Floor: . . . . . . . . Apt. No. . . . . . . . .
t
No. Dwelling Units: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. Rooming Units: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No. Stories: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basement: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Type Structure: . . . . . . . . . . . . Frame: . . . . . . . . . . . . Brick: . . . . . . . . . . . . Semidetached: . . . . . . . ... . . . Detached: . . . . . . . . . . . .
No. of Habitable Rooms: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. of Sleeping Rooms: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Owner: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-VIOLATIONS
REGULATION LIVING ROOM YES NO
7.1(a) Is there sufficient natural light?
7.1(b) Are there two separate electrical outlets in good repair? nio RCP A N/P' . &.4 1
7.1(b) Is there one outlet and one light fixture in good repair? I3e7- Piy2 TMEni?S
8.1A,8.1B(e) Is there proper ventilation?
1.3.1A Are the windows in good repair, weathertight and fit for the use intended?
13.1 Are the walls in good repair and fit for the use intended?
13.1 Are the ceilings in good repair and fit for the use intended?
13.1 Are the floors in good repair and fit for the use intended?
14.5 Are the exterior openings screened?
REGULATION SLEEPING ROOM #1 (identify) RI/
7.1(a) Is there sufficient natural light?
7.1(b) Are there two separate electrical outlets`in good repair?
7.1(b) Is there one outlet and one light fixture in good repair?
8.1A,8.1B(e) Is there proper ventilation?
13.1A Are the windows in good repair, weathertight and fit for the use intended? /« Np- S;rAy 0PF1V-'
13.1 Are the walls in good repair and fit for the use intended? s ici�
13.1 Are the ceilings in good repair and fit for the use intended?
13.1 Are the floors in good repair and fit for the use intended?
14.5 Are all exterior openings screened?
11 Is there adequate space for the number of occupants?
REGULATION SLEEPING ROOM #2 (identify)
7.1 (a) Is there sufficient natural light?
Are there two separate electrical outlets in good repair?
7.1 (b) Is there one outlet and one light fixture in good repair?
8.1 A, 8.1 B(e) Is there proper ventilation?
13.1 A Are the windows in good repair, weathertight and fit for the use intended? o,, , l/
13.1 Are the walls in good repair and-fit foe the use intended? AC,Ogf T
13.1 Are the ceilings in good repair and fit for the use intended?
13.1 Are the floors in good repair and fit for the use intended?
14.5 Are all exterior openings screened? A4 Si i 12 A-AQ 5C 17Fr'AJ �
11 Is there adequate space for the number of occupants?
REGULATION BATHROOM
3.1 Ala)3.1 B(o) Is-toilet with seat available?
3.1A(b)3.1B(b) Is washbasin available?
3.1A(c)3.1B(c) Is shower or bathtub available?
A
3.1D 3.2 Are the facilities in a clean, smooth, impervious and sanitary condition? 4 r Tu R
4.1 (9.1 &9.2). Is cold water for facilities available (with sufficient quantity)? ,�T,�- n A ,
5.1 (9.1 &9.2) Is hot water for.facilities available (120 F- 140 F)? Al , 7Fvi
9.1 &9.2 Are the facilities properly connected to drain line? Tu p R
7.3&9.3 Is there at least one light fixture in good repair? /A, 17-1.j
7.4& 9.3 Is there an electrical outlet in good repair at washbasin? /5'Sin1 C, uF/7 121A 7A
13.1 & 13.1A Are the windows in good repair, weathertight and fit for the use intended?
13.1 Are the doors in good repair and fit for the use intended?
13.1 &13.6 Are the walls in good repair and fit for the use intended?
13.1 & 13.6 Are the floors in good repair and fit for the use intended?
8.1A&8.1B Is there proper ventilation?
13.6 Are the floors and walls of nonabsorbent material?
14.5 Are the exterior openings properly screened?
=107ATIONS
• REGULATION KITCHEN YES NO
2.1 Is the roomsuitable?
2.1(a) Is the sink available and of sufficient size and capacity?
4.1(9.1 1_S cold_water for- the sink available__(w'i_thsuffiJe_n_t-quantity and pressure)?
5.1(9.1 &9.2) Is hot water for sink available (120 F- 140 F)?
9.1 &9.2 Is sink properly connected to drain lines?
2.1(b) Is there a working stove and oven?
9.3 Is the stove and oven properly connected and vented?
2.2 Are the facilities clean, smooth, impervious, nonabsorbent?
7.2(a) Is there one light fixture in good repair?
7.2(b) Are there two electrical outlets in goodrepair?
7.2(c) Are the windows(if kitchen exceeds 70 sq. ft.)equal to at least 10% of the floor area?
13.1 & 13.1A Are the windows in good repair, weathertight 6nd fit for the use intended?
kJ14-f
14.5 Are the exterior openings properly screened? I
rice
13.1 Are the doors in good repair and fit for the use intended? <-*7-A
13.1 Are the walls in good repair and fit for the use intended?
Are the ceilings in good repair and fit forthe use intended?
13.1 Are the floors in good repair and fit for the use intended?
13.6 Is the floor impervious and easily cleanable?
2.1(c) Is there adequate space and facilities for installing of Refrigerator?
8.1 A,8.1 B(a) Is there sufficient ventilation?
9.3(a)9.3(b) Are all owner installed appliances properly installed?
9.4 Are all occupant installed appliances properly installed?
REGULATIONS COMMON AREA AND EXITS
7.5 Are interior common areas properly illuminated at all times?
7.7 Are there operational and sufficient and properly located light switches and fixtures? * 'u'°
i z 71
13.1A Are the windows in good repair, weathertight and fit for the use intended? T)I
13.1 B Are the doors in good repair, weathertight and fit for the use intended? P
14.5 Are all doors screened as required? To
13.1 Are the ceilings in good repair and fit for the use intended?
13.1 Are the walls in good repair and'fit for the use intended?
13.1 Are the floors in good repair and fit for the use intended?
15.8& 15.9 Are all common areas clean?
t. 13.1 Are the stairways in good repair and fit for the use intended?
-13.3& 13.4 Are handrails in good repair and fit for the use intended?
13.5 Are all required balusters or other devices in place?
18.4 Is every entry door of a dwelling unit fitted with a proper lock?
18.3 Does the main entry door of a dwelling close and lock automatically?
18.6 Is the building properly posted with the name of owner?
3.2 Are the common bathroom facilities clean?
12.1 & 12.2 Are there sufficient and properly maintained exits?
REGULATIONS EXTERIOR
Are light fixtures and switches properly located?
tv, 13.1 Is the chimney in good repair?
13.1 Are the porches in good repair?
13.1 Is the foundation in good repair?
13.1 Are the stairs in good repair?
V/ 13.1 Are the structural elements in good repair?
13.3, 13.4& 13.5 Are all required hand railings and balusters in place and in good repair?
13.4 Are there walls or protective railings as required?
'Ale 15.4 is the storage of rubbish and garbage proper (occupants)?
15.3 Are there sufficient and properly located receptacles?
15.10 Are the private passageways or rights of way clean and sanitary?
13.1 Are the gutters and down spouts in good repair and fit for the use intended?
REGULATIONS GENERAL
10.1 Are all requiredservices.available and working?
6.1 Are the heating facilities in good repair?
6.2 Is heat being supplied at proper temperatures. (68 F-78 F)?
5.1 Are hot water heating facilities in good repair?
9.3(a) Are all required facilities properly installed and vented?
6.5 All space heaters in use meet the proper requirements?
7.9 Is there no temporary wiring in use? .Location?
7.8 is the electrical service safe and adequate?
14.1, 14.2& 14.3 The dwelling is free of insect/rodept presence?
15.7 Is the dwelling unit maintained in a clean and sanitary condition by the occupants?
REGULATION OTHER
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 Regulation 29.2 of the code or the Authorized Inspector. A.M.
INSPECTOR 'ell - TITLE A.M.
q. /sP;e,1 P.M.
DATE / 1 1 TIME
THE NEXT SCHEDULED REINSPECTION IS: DATE TIME
L A T ON SEWAGE PERMIT NO.
t 84 '
VILLAGE
IN SA LLER'S NAME i ADDRESS
Cd Itac.
BUILDER OR OWNER
DATE PERMIT 'ISSUED
DATE COMPLIANCE ISSUED
.�/11?/Q
O
.6 .
j, ` - � 1 `
No.c5/4 -7 7� � Fs /511-1
-- .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
...................OF....................................................... ...........................
Appliration for Disposal Works Tonia7an
' n Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
System at: p� (f�,,
I�r1i�...W:....� �T ............................•................._...................................................
�� zti n- ddress �
_.....
.._................................................................. .................................................
a ___•.. ner/1_...�. Gt.....----•-...... .... djes� ^ S'....................
--O V TT
Installer Address
Type of Building Size Lot............................Sq. feet
a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
� Other fixtures -----------•--------------------------------•---------.•-••••••••-•-•••---••••••••-•••-•-••........................•....•............................
W Design Flow............................................gallons per person per day. Total daily flow-------.....................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No .................... Width.................... Total Length....__. ___.�._ Total leaching area.. ..____.__. sq. ft.
Seepage Pit No----------- Diameter.... ............ Depth below inlet_1._&rr. Total leaching area3 r_�_sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
r3, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P: -----------------------------------•--------------••-------•----------•--•-•---------.........----.......------.............------------...............•••••.
0 Description of Soil........................................................................................................................................................................
W
U •-••••••••••••••••••••••••-•••••••-•-•••-•-•••••••-•....•••••._...••••••••--••••••••..........••-••••.....••-••••••••••.....•-•••-••••••-•-•••-••--•••••••••••••••••--•••.............•••••.............
W •••••••-••-•---....•-•-•---•••-•-•------••-•••••••--••••••••-••••--•--•---------•••••......•-•................. ......................-............
U Nat of Repairs or Alteration—Answer when applicable________________ ___A4t,S ... _.........................................— 6 r
.......... fr..19_04 L..... .............. ..........................................................................................................
Agreement:
The undersigned agrees to install the afore scribed Individua Sewage Disposal System in accordance with
the provisions of TITI.i 5 of the State Sanitary de—The under g d further fgrees not to place the system in
operation until a Certificate of Compliance has b n i ued b he b lth.
ApplicationApproved By ......•. •• ••-•••.. ............................................................... •••••. 2 ..................
Date
Application Disapproved f o e f owing reasons:-----•--------•------------------•----------------------------•-----------------••••............••••.....--•---
...................................................... • •....-•••--•---•••---•-•---.......•-•••-•-•••-.•••••-•••••-•••••••••••-••••••••---•-•-•-•............••---•...........-----------------------
Date
PermitNo...................................................._•--. Issued................................................
Date
No........... . . ....` FEs.....:5....................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F I-i ALTH
......................OF.....�.:....:.........:....:......::......:...... '.....
Applirutiun for Disposal Works Tons ratr#iun 11trutif
Application is hereby made for a Permit to Construct ( ) or Repair ( �an Individual Sewage Disposal
System at:
........ .....-- .........--••.........................................•--...-•------------•--••-----....------•---
UVA'f�2 �Lpcatjon�Address ' �... 1-+
a ..... ...CJJ Owner
(c ( d ess r. s
----- .
Installer Address
Type of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`14 e of Building a Other—T yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures ............-..............
------------•-----------------------------------------•............•................•-••-----------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity_........._.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width..................... Total Length...... _.__.__ Total leaching area. lr�sq. ft.
Seepage Pit No----------- Diameter... . Depth below inlet_�_.,we'. ._ ���� ----•------ P
_. Total leaching area...... ...........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.. --- ----------•-•-----•-----•-•----------------••••-------------- Date.
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
(T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
OIx ...---•-----------•--•---------------•-•..........-•----•-------....--- r----•=--•....---.........................................................
Description of Soil......................................................................................................................................
x
U .---•---------••--•-••........----•---•••-•--•--•••-•---------•----••--•-----•-•••••-----•••••----•-•••--------•--•-----•--•-•----•---------••-------•--•-------•................••••---•-•----•---•--•-
----------------------------------------•---.......---------•---------------------••-•--•--•--••-- --_=•--- r
Natu of Re irs or Alteration Answer when a licable._.Q__._�j C S _5--- t K�
U a PP --- _...US • T
•--- -- ..:............... _-••.•.... --- .•-•---.......••--•
Agreement:
The undersigned agrees to install the afore scribed Individua Sewage Disposal System in accordance with
the provisions of TITLE; 5 of the State Sanitary de—The under g d further fgrees not to place the system in
operation until a Certificate of Compliance has b en I ued b the b lth
..----•- --- ---................................
� Y
Application Approved By -•----• y� . ......... ...... 2 W4"
...........................•...----• --------------------•--------
Date
Application Disapproved for e f owing reasons:--••---------------•-------•------•--••---------....--••------....-•-----••---•--•-•----•--------•----........
. _
..----•-......... ...,......--•-......--•---------'
..................---•---------------•---•---•-•-.---•------•-••------•--•--------•--•---.... --•--••----...
Date
1
PermitNo......................•-------•-•------......-•---•----. Issued:.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF
C9rdif irFa#r of TuntlrliFatta
THI S 0 ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
bY- ))._.1�.. ...................................•-...... nstaller- ------....--•---------...........-----...---•-•---.....--••-----•-•----•--•-•---••--•-•-••-•--
pp V j�
has been installed in accordance with the provisions of TITLE 5 of h State Sanitary Code as described in the
application for Disposal Works Construction Permit No....-t1'.-_!-.-.. -��6.......... dated................................................
THE ISSUAiNC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM W L F CTION SATISFACTORY.
DATE--- ..... . .• ......................................................... Inspector.................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARgF H ALTH
CX /G ...... TM.k...............OF...... :� ..................---•--•-•--......... .No No................. ... FEE..�S. ............
iu�ruu l Turku %'Dunu#rur#iun "plamit
Permission is hereby granted = U Ve_ C@ .��'-
to Construct ) or,Repair Van Indivi ual Sew ge Disposal System
at No.----•••.1-T--�`.....�4.........
� -..._�: .... �.L.`"_�� t�l t S. �QV.4JC��}Gv�la✓� G�
-----------------------------
-------------)
Street
as shown on the application for Disposal Works Construction Permit No......... ....... Dated................................._.....__.
------------------------------------------- -------------
Board of Health
DATE...
FORM 1255 A. M. SULKIN. INC.. BOSTON