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Home My WebLink About0027 GENERAL PATTON DRIVE - Health 27 General Patton Drwe 292-112. Hyannis I I f� f i 1 �1 1 1 i a942 -i/aJ Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is / C. required for every Hyannis V Ma 02601 8/22/17 page. City/Town State Zip Code Date of Inspection �J' Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information C on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain VQ Company Name 35 Content Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 SI 13522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by t .e-Lo�- pproving Authority 8/24/17 In ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,• 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Sytem contains a 1,000 Gallon septic tank. As well as a concrete distribution box and 2 4,x30' leaching trenches. Trenches were dry at time of inspection. Future performance of leaching is not garunteed or implied. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•1113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G1M 27 General Patton Dr Property Address Edison ldrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8122/17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.•''r 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. Cityrrown State Zip Code Date of Inspection B. Certification (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 more from a private water supply well". Method used to determine distance: This system passes if the well water analysis,performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. Citylrown State. Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. CityrFown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d Vacant 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/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: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other.(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts ^W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 General Patton Dr Property Address Edison ldrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof line Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is Hyannis Ma 02601 8/22/17 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM ,•''� 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 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.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and dry 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 30 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching trenches were dry and clean. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis Ma 02601 8/22/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every H annis Ma 02601 8/22/17 y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: a ❑ Check Slope ❑ Surface water. ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 --�— "' TOWN OF BARNSTABLE LCCATION ,2.% e,��►H .� Y�' � _ "' SEWAGE r_� '.�/�i'-� VILLAGE_ 1./ a a +,5, 9 ... ASSESSOR'S �` 8�-�� J. INSTALLER'S NAME APHONE NO. CTtA,IC3 M 78 LINDEN ST. r SEPTIC TANK CAPACITY vv AHN1$, MA 02601 7 -a'L LEACHING (�YPe FACILITY, ' .renc��J (size . NO. OF BEDROOMS PRIVATE WELL ORrZUBLIC WATE�.t BUILDER OR OWNER1 '� .DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED, 7ri� VARIANCE GRANTED: Yes No I I It S 3q 3 g • r i 1i , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 General Patton Dr Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis annis Ma 02601 8/22/17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 27 General Patton Drive 10 Property Address Edison Idrovo .13 Owner Owner's Name _0 information is Hyannis MA 02601 8-1-17 required for every --Y page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, ,ZNtOF,Mgss�,�� use only the tab 1. Inspector: key to move your cursor-do not James D.Sears _ JAMES m kee the return Name of Inspector z v Y Capewide Enterprises Company Name ��'�••'.; TIC F�—� ��• 153 Commercial Street v111 5 I N S?�- ``\�� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-1-17 ctor's Signature Date The system inspector,, nspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 27 General Patton Drive Property Address Edison Idrovo Owner Owners Name information is required for every Hyannis MA 02601 8-1-17 - page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Failed system. The system is a 1000'Gal. Tank- Block c.pool leaching and two trenches. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is.available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 page. City/Town State Zip Code Date of Inspection B. Certification (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 more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes or"No"to each of the following for all inspections: Yes No Backup of sewage into facility ors stem component due to overloaded or ® El cloggedSAS or cesspool NA S 8 E£r✓ ❑ ® 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 Y2 day flow 14A S 9E& t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I� Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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. ❑ E Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box. Block c. pool and two 3' long trenches. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))� Detail: Water turned off for many years. Sump pump? ❑ Yes ® No Last date of occupancy: NADate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/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: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 - page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping.Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity.pumped determined? Reason for pumping: Type of System: ® Septic tank, 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is Hyannis MA 02601 8-1-17 required for every Y page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 34"feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage; etc.): Pipeing is cast iron and 4" PVC. Septic Tank(locate on site plan): Depth below grade: 22"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 10" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 27 General Patton Drive Property Address Edison ldrovo Owner Owner's Name information is H annis . MA 02601 8-1-17 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness A" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom-of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 22" below grade w/inlet cover at grade. In and out baffle. No sign of leakage. Tank needs to be pumped. III Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):, Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 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.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts H - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is Hyannis MA 02601 8-1-17 required for every Y page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.)- D Box is 16"x21"-26" below grade w/three lines out. Wall's are gone on box will need to replace D Box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 at 30' ❑ leaching fields number, dimensions: ® overflow cesspool number: . 1 ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a old Block c. pool and two trenches. 6' block c.pool over flow dry two row's on one side gone. Note: Old blocks falling apart. Two 30' long trenches show signs of solid carry over. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is Hyannis MA 02601 8-1-17 required for every - y page. Cityrrown State Zip Code. Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately CAR r� 0 o I 2 O 3 C2 8 -3_ 39 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 0 Estimated depth togh ground water: 1 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Const permit 5-11-95 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Const permit 5-11-95 14'+ to G.W. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM , 27 General Patton Drive Property Address Edison Idrovo Owner Owner's Name information is required for every Hyannis MA 02601 8-1-17 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Certified Mail#7006 0810 0000 3525 6351 THE ram,4 ti Town of Barnstable + iARNSPABr�, 163g6 � Regulatory Services Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 27, 2011 American Brokers Conduit 520 Broadhollow Road Melville,NY 11747 NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE CODE The property owned by you located at 27 General Patton Drive Hyannis, MA was inspected on July 26, 2011 by Town of Barnstable Health Inspector Timothy B O'Connell, R.S., because of a complaint. The following violation of the Town of Barnstable Board Code was observed: 353-1 Responsibilities of Owners and Occupants: Large amount of garbage and rubbish located within back yard of said residence. You are directed to remove the garbage and rubbish from this property and dispose of it properly within seven (7) days of your receipt of this notice. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Failure to comply with an order will result in a fine of$100.00. Each day's failure to comply with an order sha 1 c stitute a separate violation. R ER OF T E BOARD OF HEALTH Thomas McKean, CHO, RS Director of Public Health Town of Barnstable QAOrder Ietters\Refuse\27 general patton drive 7-27-1 Ldoc CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, /44 ��"�' y , hereby certify that the application for disposal works construction permit signed by me dated�i�9 , concerning the property located at 2—> G'g h a �� W� y �..`s meets 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 • 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 : DATE: LICENSED SEPTIC SYSTEM STALLER 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]. �2 `r a.r 'A 0 0 0 o s��_•! �' c � c � 00Z O c 1`5 U. . � y r l _ s. .� A ,- ' No.... .S�. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Diti-poti l Wurkg C outitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: v7 � �� 77�v ...................................................... .............................. ................................................... --•----------------------------•--•-- Loyj \ddress or N U /�+— L C 3F'•, E- a/ a W sOwner - ddres ------------ ------ --------- ----- Installer Addres Type of Buildi Size Lot............................Sq. feet �., Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures .--•-•--•------------------------------------------------------------------------ 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.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------------------------------- ------------------------------ Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-.----.---_-_---_-__-.-. f� Test Pit No. 2................minutes per inch Depth of Test Pit----------------_... Depth to ground water..--.--.---___-_--_.-.-. 0 Description of Soil----------- ------- --------- ------------------------------------------------ x V .......................................................-------•------------•••--•------•--••----•--••-------------------•----••-•-------•-••---•--•---•-- ............................................. W x -•--•------•------------ ----------•........................ ------------------------------....... ---------- U Nature o e airs or Alterations—Answer when a plic le..-. ._-.......... .......... ram' . �. ...... -------------------------------------------------------------- .......................... rAment. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the StaFtF Environmental Code—The undersigned further agrees not to place the system in operation until a Ce care of Compli rice has been issued by the board of health. Signed . i� s� \ '� Dace Application,Approved By - --- -- -- ..... ----- -- ------------- - ---4------- ... ._ .. ....... ..... ..................... .............—:Dace.................. Application.Disapproved for the following reason : - ;� Dace Permit No. +.�� .._................ Issue ........._ . I d t�ce I_ ` t F �f i`V THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE f Alrpliratiou for Di-npntitt1 Works Cfnn,itrnrtion ramit ~ Application is hereby made for a Permit to Construct ( ) or Repair ( ) ari Individual Sewage Disposal System at: r 0 P7`— ' - Loc,-�t_o� Address , por Lo?N,,) _ 1 / g ` 7 (`lt W )�A ivncr _ � ress \ i �-�y ----'•Installer ........................... � t\ t Address < Type of Building Size Lot________________ Sq. feet ----------- Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons__ ------------------------ Showers ( ) — Cafeteria ( ) Other fixtures -------------------------------------------------------------- t ` = Design Flow............................................gallons per person per day. Total daily flow----_-_____.___...................-..........gallons. WSeptic Tank—Liquid capacity-------t-----gallons Length---------------- Width---------------- Diameter---------------- Deptli___-__-_- x .Disposal Trench—No- ----- ------------- Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. 3 Seepage Pit No--------_-------- Diameter.................... Depth below inlet-----:____- Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) 1. S " �4) Percolation Test Results Performed by---------------------- _--_.._..____ Date........................................ Test Pit No. I------x........minutes per inch Depth of Test Pit------------------• Depth to ground water_-___.----:___-__.._.. . 44 Test Pit No. 2.........._.....niinutes'per,inch Depth of Test Pit_--_-__-_-_--_____.`.Depth to ground water........................ t -s .. ------------- O -Description of Soil ------------------------•--••------------------- ----...----------...---------------------------------------------•--------------. x U -•--•••••-•••-••-•••...---•--•---••-•••-------------•-----------------------••-••----•---------....---------=---------•----•--•----•---•---------------------------------------- ---- --- --- - -- x = = ,...�-------- w --- --- •y ------ . - U ; �2ep Iterations—Answer when a pl•ic le---- ----------------------------- ----------------------------L--......_-_.__.-_-__. _. Nature f - r - .- �"r` r r� - - h------------------------------------------------------- ------�!--------•-------•-•-•---. A!gfeeme t: f? The undersigned agrees to install the aforedescribed-Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of-the State Environmental Code —The undersigned further agrees not to place the system in operation until a Cer �ficate of Compliance has been issued by the board of health. Signed .. ---t..... -�/ '°�� ----------- ...... '/ .... .............. �j,�..,, ® Date ApplicationApproved By .....:... '- -.-----....... o........ --C................ ---------------- ----------------- / Date Application.Disapproved for the following reason V------------_------------------- ---------------------------------- ------------------ Date Permit No- - ---- ------- ....... -------------- Issued ....... .. -- 1-- --------.. • ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE T.Wrtificttte of C�IIzttpliance THIS IS TO C-ER.TIF hat the ndividual Sewage Disposal System constructed ) or Repaired g P Y ( P ( ) G^--2' ' by ... ..... ..... \ -. ............._..- nstatia at ......... ------------------------------ .-----------------------------------._....... __....- -.... �4 - has been installed in accordance with the provisions of TITLE 5 f T e Sta e Muir mental Cooe�as described in the application for Disposal Works Construction Permit No. --_ -- •''�J �j.. dated ......._..........................__....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. &' _ DATE-----. _/../..". ! .` Inspector . + --------------- '� THE COMMONWEALTH OF MASSACHUSETTS Ord BOARD OF HEALTH TOWN OF BARNSTABLE No...... . ........... k FEE.... ......... Ui .1 Workii nolnution "an it Permission is hereby granted_-,C _•_ % to Constr ct ( ) or Repair ( a� Individulal ,ewa e Disposal S st - � at N ''r ) A ..................�-•-==�� ...... ..... ..........-- j< l-,_ / stfeet / as shown on the application for Disposal Works Constructto Per itNo,�_______------_//Dated__-_-_...----_� /-r-- Board of Hea tl1h t DATE............... t............................................. FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS AJ �--�� Town of Barnstable Health Department { 1 36 7 Main Street Hyannis, MA 02601 .... Y ,6,q. Office508-790-6265 Thomas A. McKean FAX 508-775-3344 of pp�� c Health September�0, 1.99� Scott Colantonio 25 General Patton Drive Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00 STATE SANITARY CODE II MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE ARTICLE 51 The property owned by you located at 27 General Patton Drive, Hyannis was inspected on September 16, 1996 by Christina Kuchinski, R.S. Health Inspector for the Town of Barnstable because of a complaint. The following violations of the Town of Barnstable Rental Ordinance Article 51 and the Sanitary Code H were observed: 410.351: Water was dripping from the faucet of the kitchen sink. . 410.552: The front entrance storm door was not closing fully. 41 The self-closing device for the front entrance storm door was not functioning. You are directed to correct the above listed violations within seven (7) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, this violation must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OV THE BOARD OF HEALTH Thomas A. McKean Director of Public Health cc: Al Farren: 2 7 Gees►-�-f � " 'Ale �.Y►v� s� j/y)'19 Lea6 U 0 Spa-�—� Cali 'o Mom. as G � l p� I- NOTICE TO ABATE VIOLATIONS OF 105 CMR 410,00, STATE SANITARY CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 6"7a-,- ram'' �`was ins The property owned by you located at a 7 petted on 9 �(�/� -W4 by�v, J�D Ilealth Agent for the Town of Barnstable because of a complaint. The following violations of the Town of Barnstable Rental Ordinance Article 51 and the Sanitary Code 11 were observed: yw, 3si CJaJf�a- was ar e n � u� how �i�s%v►� e)Go._Y no . Y . Ymic;ee direct to e vio o � ce f by You Are*'directed to correct the remaining above listed violations within seven (7) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of I lealth within seven (7) days a[ler the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate (lay's failure to comply with an order shall constitute a separate violation. You are also subject to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. Enclosed are citation numbers due to violations observed on PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health Town of Barnstable i FORM30 HOBBSa WARREN,INC.NOV.1979-19e3 THE COMMONWEALTH OF MASSACHUSETTS g2��12, '. BOARD OF HEALTH CITY/TOWN / a DEPARTMENT ko, s ADDRESS S_ TELEPHONE C, Address Z) Occupant )4-1 Floor Apartment No: No.of Occupants No.of Habitable Rooms No.Sleeping Rooms <4— No.dwelling or rooming units . No.Stories, Name and address of owner G-t�'f''f ( ,)t CL4-4-n,z /,-D 0E'Y�Oil7c/ - A_4 b L^ �r�uP. �LjCt vv1 S Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: , STRUCTURE EXT. Steps,Stairs, Porches: Vr (,p Jk U/i yA pA`i -7r--q ; Dual Egress:and Obst'n.:" 1 r,-rr • , ❑B ❑ F ❑ M Doors,Windows: �- Roof rl(l)l/ v► l 1, Gutters, Drains: 0-4-'6-v—fA4 r 'f�,; - A-A-4' -4-b 1A.' ,,, Walls: -4-n A k Foundation: Chimney:_ BASEMENT Gen.Sanitation: Dampness: ( /,TO t h—�') UP -V nwX.1--1 Stairs: , � 1. Lighting: STRUCTURE INT. Hall,Stairway: v Obst'n.: Hall, Floor,Wall,Ceiling: 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.: ❑ 110 ❑220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. Lgtnq. Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Livina Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facll. Vent.,Plumb.,Sanit'n.: Wash Basin Shower or Tub: Infestation Rats,Mice Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY," it( INSPECTOR ��+44� �6,4r TITLEl DATE � TIME �� P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. y 410.750: Conditions Deemed to Endanger or Impair Health or Safety pi The following conditions, when found to exist in residential premises, shall be deemed conditions which may.endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter lI, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations may not be found to fall within this category. Nor shall failure . to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is ' issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. - (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D) Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253(A), 410.253(B) and the lighting in common area required by 105 CMR 410.254. (E) . Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G). Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to comply with the security requirements of 105 CMR 4110.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602 which results .in any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or .. spread of disease. (J) The presence of lead-based paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and.Control 105 CMR 460.000. (R) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or dafety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted .plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilities as are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: . (1) lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. (3) any defect in the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted plumbing heating, gas-fitting, or electrical wiring standards that do not create an immediate hazard. W_ failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the board of health. AsBuilt Page 1 of 2 TOWN OF BA�RJNSTAfB�LE LOCATION USEWAGE # VILLAGE �44 2w� 3 ASSESSOR'S MAP I:Q J. CrA.IG MEDE OS INSTALLER'S NAME & PHONE NO. 78 LINDEN ST. ANNIS,MA 0260f SEPTIC TANK CAPACITY /vv o r LEACHING FACILITY:(type � �.,lie //g--l__(sizc NO. OF BEDROOMS Z' PRIVATE WELL OR�LIC WATEJ' BUILDER OR OWNER DATE PERMIT ISSUED: J l/_ _ DATE COMPLIANCE ISSUED 7 f� VARIANCE GRANTED: Yes No &-G'44 ci a/ 0"r17)^ -yl-lve 1 S�� 3 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=292112&seq=1 2/13/2017 Message Page 1 of 1 Anderson, Robin From: Anderson, Robin , Sent: Tuesday, January 19, 2010 1:50 PM' To: John Cosmo ocosmo@hyannisfire.org); dchase@hyannisfire.org; Police Chief; Tamash Craig Cc: Perry, Tom Subject: 27 General Patton Dr., Hyannis FYI: Just wanted to make you all aware that a complaint made to the Health Division identifies 27 GP Dr as being abandoned approximately 2 months ago. It is.reported that the pipes are frozen and the front door is not secure. The property owner, Attorney Alec Sohmer was under investigation by the AG's office for fraudulent foreclosure rescue. It now appears that he has walked away from this property and I am additionally informed that all attempts to reach him have been unsuccessful. No official notices have been posted but with a lot of winter still ahead of us I thought emergency response personnel should be aware that there is a potential squatter situation at this address. 'R96in Robin C. Anderson Zoning Enforcement Officer Town of Barnstable 200 Main Street Hyannis, .?vial 026oi .5o8-862-4027 t 1/19/2010 LOCATION SEWAGE PERMIT NO. b �IE3v D� VILLAGE I N S T A LLER'S NAME & ADDRESS J. CRAIG MEDEIROS YS04 142 Corporotlon Sheet 46 1 L D E R OR OWN ER tiyainnis, MM. 77 2S DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 04 d G' t � Fxs..... .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ....... D....`....^.............OF_........:............ Appltrativat for Uiupuuaal Works Cult trurttun prutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .....«...__._.._._«.................................................... ................. ...._ .... .. ........... .. .....V-_............. ..........................« cati s W� f r Lot No. . leo --•-- ..._ ................................. ------- ----- -- `.. .... . --.............................v �T «.« O ner r Add ess Installer Address TyBuilding Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons---..------................. Showers ( ) — Cafeteria ( ) Q' 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.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................---. - O Description of Soil-------c_�-----�_-- ------- �- ---- ----------- -- -----------------------•---......................-------•----•----------...---......-----•---••---- a—...Y.................................................... ------------------------------------------------•-----••--••-------------- _ W -----------------------P-----------------------------------------------------------------PP------------ --------------------------------------------------------------- x - cable- �(�f-�� ___M. #.�---�- .•. ---K --5 . ,: - Nature off Repairs or Alterations—Answer when a li Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'i TIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een i d by the board of health. l SigL ................ ...... te- ----- Application Approved BY r ------------------•--•---------- ------/Z •�� ......------ Da e Application Disappr e e following reasons:--------••-•-----•-------------•-------•---------............................................................ ................................. .----------•------------•---...--------------•-•- --------•---------------------------•----•------------------- y--•--•-•--•----Date--•--••-•----- PermitNo......................................................... Issued_...........................fi -----•------------ Date i-. No....../' 7 Fizs........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD_.OF HEALTH ' w Fn.............OF...... '3 ..`........................................................... ApplirFa#ion for Disposal Works Tomlrurtion Trait Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: " s . .. ._ .......................................................... ocatioa dr sC�pozq Lot No. V6 �'6o r ... ...........- _.-.. -... .. ..�'`-- . c ✓. -- ------------•----•--- �/�Oner • �I /' / +�A,ddress a ......'_..Sr:-'-".::"'�.A�'l",f _J' " '• ='-f '= . `I�' 1.'. . .�...... ....C-...�...... `L!_.......a ....:_.._':r?e:. t�,i,V..::a Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------• . - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No---------------_--- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-----------------------•------------•----------------••-•-•--•--••------• Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ <--"--------------------- --•---------........................---••-----.._...._••--•..•••........................................................... 0 Description of Soil...... .............................•---.....---------------------:..------•----- V ......-----•-•••-•---••••-••-------•--•--••---••••••--------•---•-•-•....----•-----•-------•-•••---•-----------------------------•--••---•--•---•-•------......_.....----•--•----•-•--•-•----.••---••--- W -------------------------------------•---------------------------------------------------•••--••-• . - ---- ............................................- r ", x Nature of Repairs or Alterations—Answer when applicable I -''� : --`...... :f' 3 � -- s!� W $ �a... ... . . . .. ...__ .� K.... _ -- Agreement The undersigned agrees to install 'tthe aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTTs E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een i d by the board of health. Application Approved By....-. -----... •... ............... ••.01 ............... ,/ Date Application Disapprro;e f er jhe following reasons------------------------•--------------------------------------•-----------------•---...... -----.....-•---•--- �..✓' .. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............0 Feo .c. r*' " ................................................. (Entifiratr of TontpliFanrr TK S I&Tp CERTI Tha the Jnd MI5.1wRtwage pisposal Sy constr e (I�� or Repaired ( Cs by .` '-e"`--.---------�'--------- 'x`` '8^ -... ..„/ Install at---•-••--- �"'.......---•------ •---------------------------( .--�'� :tom ------.../---• .. ...---••---...---.._......------•-----------. has been installed in accordance with the provisions of TIT i F-; 5 of The St Sanitary Cod as escribed in the application for Disposal Works Construction Permit No..__��_"_.�_�............... dated_..�f.......'�__.�!,�....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................ L!- I;&Z_A' .................................. Inspector...•....--....J;g 41 -�................................................... ... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ., ....... Disposal Marks Tonoir ton rranit Permission is hereby grante --.' _ -„�.-- �� .. ... �3s to Construct o Repair ) ,r e age Disposal,Systei -- Street ' as shown on the application for Disposal Works Construction Permit No..................... Dated...... .J .............. ----•-........---•---------------------------------------------•-------------------.......----••---•---- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TOWN OF BARNSTABLE LCC i� TION -�= =" _ Gv� �'`e "0 1")t�- r"?,) SEWAGE # (� v / 1e Y/ q VILLAGE G' ' ASSESSOR'S MAP & LOT �1/� J. CIIA.IG MEDEIIR,OS INSTALLER'S NAME &• PHONE NO. 78 LINDEN ST. ANNIS, MA 02601 , SEPTIC TANK CAPACITY LEACHING FACILITY:(type) elf (siu ` NO. OF BEDROOMS PRIVATE: WELL OR6RUBLIC WATEJ1 � BUILDER OR OWNER .DATE PERMIT ISSUED: -// DATE COMPLIANCE ISSUED: V-ARIANCE GRANTED: Yes No `� w - x ai,.