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Home My WebLink About0005 HOLIDAY LANE - Health c 5 H.o:!9,day mane fx Hyannis F A =-267 084 �j I r t d H 8 a 1 �I 1 rd o Q TOWN OF BARNSTABLE LOCATION H Q m y Ave, SEWAGE# "' ILLAGE ASSESSOR'S MAP&PARCEL 2-4r,-7 LO fY INSTALLER'S NAME&PHONE NO. 6mQP_ vD c.��, Em- �n►'s� cam. m W SEPTIC TANK CAPACITY LEACHING FACILITY:(type) eal leas (size) '2 6 t 3 NO.OF BEDROOMS OWNER Ca�� PERMIT DATE: '��3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY C.4P.W6 6 "6)11kr "I t4 l'� F9 Q / 9' a/7j� No. o {S Fee leV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for Mi5po5al *pgtem Construction Aermtt Application for a Permit to Construct( ) Repair 0() Upgrade( ) Abandon( ) ❑ Complete System 5<Individual Components Location Address or Lot No. f-f O L 1 04 q CAM G Owner's Name,Address,and Tel.No. HYAO r S sT F.PµW Cep S4L,C 7M5 Assessor's Map/Parcel ZZ Rq 34 uueo G. Installer's Name,Address,and Tel.No. S6 Tr-N71 -ETq'1,7 Designer's Name,Address and Tel.No. Cfh�t�vlb� (5):T $EK, Type of Building: A',, Dwelling No.of Bedrooms Lot Size • v1 q 4(k("g soft' Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) G 1V E C46W_Gd5 -POa t l-�c,�S 6 -C*0 K Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign d - Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. � Date Issued_ r'j 21 D- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplicotion for Migonl �&p$tem-Cowgtruction..Permit Application for a Permit to Construct( ) Repair 0<) Upgrade Abandon( ) ❑ Complete System g Individual Components Location Address or Lot No. J� t{p(.1 Dd4Y (-Am G Owner's Name,Address,and Tel.No. Hvd0N/S sTEPffE'IJ CAS4LC- -Ms Assessor'sMap/Pazcel 1 . 34 6-LC.�•1J � l4s(�.?S�iv P-M Installer's Name,Address,and Tel.No. Sd S-y71 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size ♦ of AfZK s Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min:required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil . Nature of Repairs or Alterations(Answer when applicable) G I AI6 <CALF�dVGIZ- :I�Ekvu e �-6.g 6 im T4A)V, Date last inspected:; Agreement: :,t. - The g undersigned agrees to ensure the construction and maintenance Y g P ance of the afore described on-site sewage disposal system in g e Environmental ode and not to lace the system in operation until a Certificate of accordance with the provisions of Title 5 of the E o C p y p I{ Compliance has been issued by this Board of Health. Signed Date Application Approved by_ Date (`6 eZ1iO�. • Application Disapproved by: Date ' for the following reasons f Permit No. -0 �-- / Date Issued , L � THE COMMONWEALTH OF MASSACHUSETTSi BARNSTABLE,MASSACHUSETTS G Certificate of Compliance THIS IS TO CERTTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( x) Upgraded ( ) Abandoned( )by eA0a,)ro t5 E�u 7 i A/1/SE 6 at 5 H U(-lD.EY LAxj< y AN1cJ!S has been constructed in accordance 5/J with the provisions of Title 5 and the for Disposal System Construction Permit No. JP f 3 7 dated 3 Installer CAP&kvi D6 Designer #bedrooms Approved des]g w �rA A gpd o The-issuance o th'� i s 1 not be construed as a uarantee that the s stem wi £�5nc o ees, n%e�' Date g Inspector C /" P , No. (J� 3 cam- / Fee / 0 C) THE COMMONWEALTH OF MASSACHUSETTS �--� PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1=i!9tJogar *p5tem Con5truction Permit Permission is hereby granted to Construct ( ) Repair ( X) . Upgrade ( ) Abandon ( ) System located at .7 t4o(,t7)L�y LA-NE H lAi !U/ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must)be completed within three years of the dat of:thli*sermit: Date /s�� Approved by v No. � �'� Fee �d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Y 2pphtation for Disposal 6pstrm Construction permit Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System V Individual Components Location Tress or Lot No. }i 6 t ay �0-_� Owner's Name,Address,and Tel.No. YO — oZ p—6 6;Z �D Assessor's Map/Parcel 4,7 O$ Installer's Name, gAddress,and el.No. s6�—977 a$B-1 7 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size • sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r, 6°^Se- Nature of Repairs or Alterations(Answer when applicable) 1�� a... 0.1 � 1 e, 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 Certificate of Compliance has been issued by this Board of Heal t Signet, Date '7;JZ Application Approved by Date Application Disapproved by Date for the following reasons Permit No. / -- — Date Issued �'� No. C�/n-v/ l` ^ s Fee OO C Entered m computer: ti - THE COMMONWEALTH OF MASSACHUSETTS p PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS pplitation for Disposal 6psteniZonstrUttion 3permit Application for a Permit to Construct ,'Repair Upgrade Abandon pp ( ) (�/S� pg ( ) (�) ❑Complete System 2 Individual Components Location Address or Lot No. 5 dt0. L0� �R Owner's Name,Address,and Tel.No. y� Assessor's Map/Parcel r Installer's Name,Address,and tel.No. 09-977—?5'7 Designer's Iklame,Address,and Tel.No. ✓ ' Co,,,�2Wta�2, ��'acgriSC'.S , �"1QSh��►��r, Type of Building:Dwelling No.of Bedrooms Lot Size *;t ((/ A sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers yp g ( ) Cafeteria Other Fixtures t Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil - Nature of Repairs or Alterations(Answer when applicable) 1 Q - j "�j L � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore describe d on-site-s6age disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health- Signe Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. / — ' 10;i Date Issued ' - == ---------- ---------------------- - -THE COMMONWEALTH OF MASSACHUSETTS R BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired ) Upgraded( ) Abandoned b C 0 ( ) Y at A"DY. has been constructed in accordance with the provisions of Title S dd the for Disposal System Construction Permit No.DL -�nejdated Installer! 1141 0�v_E h�� t. s e--s Designer #bedrooms �j Approved design flow '�� gpd The issuance of this permit sh 11 not be construed as a guarantee that the system will function as designed. 't Date jam'"Z. Inspector r No. d1 C?` . - lr __ - - Fee co - -THE COMMON-WEALTH-GF MASSACHUSE-TTS' --�- -- -� PUBLIC HEALTHTDIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction permit - Permission is hereby granted to Construct( ) Repair( Up ade( ) Abandon( ) System located at 5 d` r `-- VN JZ— V . t and as described in the above Application for Disposal System.,Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. - , if ' 3 Provided:Construction must be compl ted within three years of the date of this permit. Date �� 2Z Approved py TOWN OF BARNSTABLE .� LOCATION,5—/-/U SEWAGE# /Sp VILLAGE/. r-- ASSESSOR'S MAP&PARCEL,:,?(b INSTALLER'S NAME&PHONE NO. �• t SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /-//U (size) , 3.S�-< cF6 i(o NO. OF BEDROOMS OWNER. PERMIT DATE: �Z S COMPLIANCE DATE: Separation.Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet ~ Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY_..�T&5dy\ A sgtf Z9___-- E I e 3 661-0 '3 Zz% 35-L- Z 3 '—<) 4 3 S- 3'' 6- G 3G s av i Town of Barnstable Barnstable t"aF .�. Regulatory Services Department AFAmedcaMW • BARNSTABLB. • I � ' MASS. ,. Public Health Division fD"" A 200 Main Street, Hyannis MA 02601, 2007 m Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO 03/16/09 Stephen Casale _ 34 Ellen Lane 1 O i Cranston RI 02921 - FINAL ORDER ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at, 5 Holiday Lane, Hyannis was last inspected on 01/12/2004, by John Graci Inc.a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: `.`Single cesspool automatic failure-the cesspool is structurally unsound and the stain lines indicate the cesspool has been full" The deadline for repair 01/12/2006 has past. We, The Department of the Board of Health, have not been informed that you have taken any steps to bring your failed system into compliance. Therefore, you are ordered to repair or replace the septic system within 60 days from the date you'receive this notification. You may request a hearing before the Board of Health, a written petition requesting a hearing on the matter, within seven (7) days after the day this order was received. Failure to.repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Th as McKea , R.S., CHO Agent of the Board of Health Certified Mail#7003 1680 0004 5458 4395 P�OpIHE Tp Town of Barnstable v O " Regulatory Services Y # Y IIAEtNSTABLE, Y ' MASS. mQ Thomas F. Geiler,Director 039. AIFD MA1' Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 7, 2007 Stephen &Rosemary Casale 34 Ellen Lane Cranston, RI 02921 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. t The property owned by you located at 5 Holiday Lane Hyannis,was inspected on June 1, 2007 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the Town of Barnstable Code were observed: 070-10—Smoke Detectors and Carbon Monoxide Alarms. Inoperable smoke detector in bedroom on right; no CO detectors provided. You are directed to correct the violations listed above within twenty-four(24) hours of your receipt of this notice by repairing or replacing inoperable smoke detector and by installing CO detectors on every habitable level in accordance with Mass State Fire Codes. 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. QAOrder letters\Housing violations\Rental ordinance\.5 Holiday Lane.doc 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 T BOARD OF HEALTH Tho as A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Timothy O'Connell, Health Inspector QAOrder letters\Housing violations\Rental ordinance\5 Holiday Lane.doc I FORM30 C&W HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD �=FH CITY TOWNALI W D PARTMENT ADDRESS Csv Ci/ _ g6c(LI _J TELEPHONE Address _ Occupant__ IrDzv.�--tZ6 Floor Apartment No. of Occupant No.of Habitable Rooms 7 No.Sleeping Rooms No. dwelling or rooming units .Stor' s Name and address of owner emarks 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: 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. 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.: s, Flu s Ve is es: Kitchen Facilities Sin - rove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE 404 OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See tINED7AND "THIS INSPECTION REPORT CERTIFIED UNDER T E PAINS AND PENALTIES OF PERJURY." ----------- '< TITLE DATE ` ® TIME A.M. P.M.THE NEXT SCHEDULED REINSPECTION 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. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105. CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof;foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) .Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. i Town of Barnstable THE o Regulatory Services �W.,,, M ; Thomas F. Geiler, Director 9 16,19. Public Health Division Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 11, 2007 Attn: Hyannis Fire Health Inspector Timothy B. O'Connell conducted a rental inspection in accordance with Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector(and\or CO detector) violation(s): 83 Breakwater Shores Dr Hyannis,Assessors Map-Parcel: (306-227): No CO Detector in home. No Smoke Detector in basement. 19 Redwood Ln ext. Hyannis,Assessors Map-Parcel: (288-084): No smoke Detector in basement. No CO within basement 5 Holiday Ln Hyannis,Assessors Map-Parcel: (267-084): Smoke Detector not working near bedroom on right. No CO's within home. Timothy B. 'Connell-Health Inspector QAOrder letters\Housing violations\Rental ordinanceUire ViolationsTIRE TEMPLATE.doc `~ Town of Barnstable P# I gyp' Department of Regulatory Services Public Health Division DateNAM l 200 Main Street,Hyannis MA 02601 Date Scheduled G' Time Fee Pd, Id0 Soil uitability Assessment for Sewage Disposal Performed By: 2M Witnessed By:Day✓tp L11. n /® i LOCATION& GENERAL INFORMATION 5Location Address Owner's Name �Qmcty, �Q Q�(>,j 1 'l.' Address CGS SO�e Assessor's Map/Parcel Engineer's Name 0 � Q SV L7—1 NEW CONSTRUCTION REPAIR Telephone# 3 Land Use 2e11decINSeN Slopes(%) cR qc Surface Stones Distances from: Open Water Body N I.a ft Possible Wet Area _ft Drinking Water Well LI 1i ft - Drainage Way, ft Property Line I-45 ft Other 61 /A, ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands In proximity to holes) CSC ` a Fv i -11 Ciro oa co r— Parent material(geologic) tJ`��cSI r Depth to Bedrock fA Depth to Groundwater. Standing Water in Hole: NQfV tb jrha.@_ Weeping from Pit Flee NQVQ des_ I?att i3a►" Estimated Seasonal High Groundwater 1 2) f}C, smoA DETERMINATION FOR SEASONAL HIGH'WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: jn, Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level, Adj,faethr— Adj.Groundwater Level PERCOLATION TEST Da to 5.: U5Thne L'acj 01-' Observation ��., � Hole# Time at h° Depth of Perc —�-i t Time at 6" 1 Start Pre-soak Time @ fl: - Time(9"•6") End Pre-soak Rate Min:/Inch Site Suitability.Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTICNPERCFORM.DOC - DEEP.OBSERVATION HOLE LOG Hole# t Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,,Boulders. Consistency,% ravel to ya NSA to O t� l_S 0�cs�.Xl. DEEP OBSERVATION HOLE LOG Hole# �-k _ Depth from Soil Horizon Soil Texture Soil Color -Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% ravel t G' ✓ L5 Q S M-C DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consisiena. h DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency. Flood Insurance Rate Map: Above 500 year flood boundary No Yes :_ Within 500 year boundary No Yes Within 100 year flood boundary No✓ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in,all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material?-_.h4� Certification I certify that on kk (D (date)I have passed the soil evaluator examination approved by the Department of Environmental.Protection and that the above analysis was performed by me consistent with . the required traini ex i)erNse and experience described in 310 MR,15.017. Signature Date Q:\S.EFTICVERCFORM.DOC r FKLEO INSPECTION COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS T DEPARTMENT OF ENVIRONMENTAL PROTECTION Z >n � y d F MAP �Z n�O1 6"o PARCEL,, 13 %4. LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 5 HOLIDAY LANE HYANNISPORT 02601 Owner's Name: MARY ROTONDO RECUIV , Owner's Address: 295 C SCITUATE AV CRANSTON RI 02921-1820 f Date of Inspection: 1/12/04 FEB 0 i) z6j4' Name of Inspector: (please print) JOHN GRACI,INC. TOWN U�i�rrarv;'s,�c>�. Company Name: SEPTIC INSPECTIONS HEALTH Q�P1" Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 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 _ Conditionall asses Needs Furt Evaluation by the Local Approving Authority X Fails ' i, Inspector's Signature: "' Date: 1/12/04 ,r The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec,on. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments THE SYSTEM FAILS TITLE V INSPECTION. THE SYSTEM CONSISTS OF SINGLE CESSPOOL AND DOES NOT MEET TOWN OF BARNSTABLE TITLE V CRITERIA-THE CESSPOOL IS STRUCTURALLY UNSOUND AND THE STAIN LINES INDICATE THE CESSPOOL HAS BEEN FULL. ****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. Tit1P. 5 Imnactinn rm F/l s/?nnn 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5 HOLIDAY LANE 14YANNISPORT 02601 Owner: MARY ROTONDO Date of Inspection: 1/12/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM FAILS TITLE V INSPECTION.THE SYSTEM CONSISTS OF SINGLE CESSPOOL AND DOES NOT MEET TOWN OF BARNSTABLE TITLE V CRITERIA-THE CESSPOOL IS STRUCTURALLY UNSOUND AND THE STAIN LINES INDICATE THE CESSPOOL HAS BEEN FULL. 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. n/a 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 irmninent. 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: n/a n/a 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: n/a n/a 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 I ND explain: n/a Page 3 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5 HOLIDAY LANE HYANNISPORT 02601 Owner: MARY ROTONDO Date of Inspection: 1/12/04 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 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 n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5 HOLIDAY LANE HYANNISPORT 02601 Owner: MARY ROTONDO Date of Inspection: 1/12/04 D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to 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 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 nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of 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 1 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. (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 (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. 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet 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 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. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 5 HOLIDAY LANE HYANNISPORT 02601 Owner: MARY ROTONDO Date of Inspection: 1/12/04 Check if the following have been done. You must indicate "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 Were any of the system components pumped out in the previous two weeks X Has the system received normal flows in the previous two week period`? X Have large volumes of water been,introduced to the system recently or as part of this inspection? _ X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ 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 `? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ X Existing information.For example, a plan at the Board of Health. X _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 5 HOLIDAY LANE HYANNISPORT 02601 Owner: MARY ROTONDO Date of Inspection: 1/12/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: n/a Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): YES Water meter readings, if available(last 2 years usage(gpd)): O 3 _ S�AOd CA_Q1I(_A__T_ Sump pump(yes or no): NO Ua _ 4(3 ';�p6 Last date of occupancy:itis C1 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): 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/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection (yes or no): NO If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM _Septic tank, distribution box,soil absorption system X Single cesspool Dverflow 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): n/a Approximate age of all components, date installed(if known)and source of information: OVER 30 YRS PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 HOLIDAY LANE HYANNISPORT 02601 Owner: MARY ROTONDO Date of Inspection: 1/12/04 BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: (locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: n/a Sludge depth: n/a Distance from top of sludge to bottom of outlet tee or baffle: 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 How were dimensions determined: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): n/a 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(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 HOLIDAY LANE HYANNISPORT 02601 Owner: MARY ROTONDO Date of Inspection: 1/12/04 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): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX: _(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): NONE 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 R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 HOLIDAY LANE HYANNISPORT 02601 Owner: MARY ROTONDO Date of Inspection: 1/12/04 SOIL ABSORPTION SYSTEM(SAS): _ (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): n/a CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: 5' X 2"' Materials of construction: BLOCK Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): THE SYSTEM CONSISTS OF SINGLE CESSPOOL-WHICH DOES NOT MEET TOWN OF BARNSTABLE TITLE V CRITERIA-CESSPOOL IS STRUCTURALLY UNSOUND AND SHOWS SIGNS OF BEING FULL. CESSPOOL WAS EMPTY AT THE TIME OF THE INSPECTION. BOTTOM IS AT 3' 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 4 Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 HOLIDAY LANE HYANNISPORT 02601 Owner: MARY ROTONDO Date of Inspection: 1/12/04 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. In Page 11 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 HOLIDAY LANE HYANNISPORT 02601 Owner: MARY ROTONDO Date of Inspection: 1/12/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER NO WATER AT 10 ti C�tATION SEWAGE P E R Mflk N r� Y1LLAGE �76 INSTA LLER'S NAME i ADDRESS Ca /? c - �--I'� t�I�P y% 2 ti h o,4, 2c-o `Y/Z r`h i w e-dT' zss S' t�12 V r�ov� dY! R U I L D E R OR OWNER DATE PERMIT ISSUED 8 DATE COMPLIANCE ISSUED 1 , -r7 e � o Nt S�� ro N 2 f A ,1 v Z 03nSs1 33Nv11awo3 3111a aInssl lIlNN3a 3111Q a3 NAAO 80 a 3 a 11 n I /y --7yNlbt Df al v7 SS3yoaN 1 3wvm S.N311 VISNI 19V11.1A. �� 3 � �b►� 8 b� +`- ON 11093a 39MAA3s c a Nollv3 -ol G O r G G � o � c� No...g5-4 Cr1 THE COMMONWEALTH OF MASSACFiUSETTS BOAR OF HEALTH m .............OF_...... - ... .....................� 0`-�� Appliration for Disposal Works Tonstrur#inn Vamit Application is her y made,for, Pe,>�rmit to Construct ( ) o epair ) an Individual Sewage Disposal S tem at: �'/cMi ..... .... .r� v i Location-Addre l ..................................... •••...... ..........................---...---•-•--- �/f .......... ... ..... --- .. as a ...�r. —` e h-•-•_•.'•+l�l y � `l •...Installer Ad ress UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—.Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ......................... ............................................................................................................................ 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................. _... a -------•----------------------------•----•----•--•----......----•-........-----.............................................................................. 0 Description of Soil....................................................................................................................................................................... ------------------------------------ •----------- .......... •------------------------ •--------------------------------- ---------------------------------------------------- •------------- ---------- -- ;;fi�rr ------------------------ V N ture of R,ygairs or Alt rations—Answer wh a licable_.1�._.- !?._ ___ �!.,� _.. .t_ r Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 7 the provisions of TITLUj 5 of the State Sanitary Code—The undersigned further agrees not to place the system,in operation until a Certificate of Compliance has bee by the oa o ealth. Signed -_... ••• • • . -•------•-•-------. Application Approved By.......... 'fir'...-----•--...-------•----•--•-•..... .... .................. ate ------ ^-------- ate--- -- --- Application Disapproved for t following reasons:_..--•------------------------------•------------------•------.......--------------------------------...-•-••- ..•--•..............••----•-••----•-•-----•-•---......----•--•---••---•--••••-----•--•-•--•••-----•-------•--•----••----•---------------------••...•-----•----------------------•-------------•••------ ate Permit No........• C.�:_.....•----...... Issued....................................................... Date 7W No...................... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARP—.,,OE HEALTH 5 OF.. t> L, 4, A . ...................... .................................. .............................................. Appliratiot.t for Disposal Works Tomitrurtion thrmit Application is hereby made for a Permit to Construct op"`'Repair an Individual Sewage Disposal SVsteM at: ...... ..... Location Add re s.7- or I.St No. .......(A.2;...... . ....................... .................................................................................................. Owner ,Addle,- .......................... ............... ,A ................. ---------*......... 1 '. Sow, ..... '& ...XZ.e..'.. im'ja r Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder a Other—Type of Building ............................ No. of persons............................ Showers Cafeteria1 Other fixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 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. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by.................................... ..................................... Date..................................I------ Test 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.._.._.............._._. ...........................................................*-------------------- .......... -------- --------------------------"----------- 0 Description of Soil............................................................................................... ..........._........................................................ W U ........................................................................................................................................................................................................... ...................... ................................................................... ...........L....... .,'*............ S4 g e ,airs or Alterations—Answer wh n a N tune of Repairs ... ...........S U ...�0;� " , I ............... ...... ...... ...............j.......................... Jaz.... ................... ...... .......)N. . ...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to,place the system in operation until a Certificate of Compliance has bee issued the, o y . `the, of health. Signed ... ............ ..................... 4ate Application Approved By......... .1v......................................... .................. ate Application Disapproved for t following ollowing reasons:.............................................................................................................. ....................................................................................................................................................... ------------------------------------------- Date PermitNo........ ................. .................. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.......... .......................................................................... dle ClEntifiratr of Tompliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by---------------------------------------------------------------cett4 N CO ........ ........................................................................................................................... 91 Installer at......................7 ......)......... - ......"* il... PQ...................................................................... has been installed in accordance with the provisions of TITLE r of The State Sanitary Code as described in the application for Disposal Works Construction.Permit No.., . 4-54............. dated........................_..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRIBE® AS A GUARANTEE THAT THE SYSTEM WIL SATISFACTORY. DATE.............. .......................... Inspector....--- ......... .. ..... .............. 71ON .. .......... .......... THE COMMONWEALTH OF MASS CH SETTS BOARD OF HEALTH .......... ................................OF............... ...................... No......................... FEE. .................. Disposal Workii Tonotrudion ,anfit �0Permission is hereby granted.............0---0.8....C__fW.1.VqA1........... 6 4.....I tv. . ..... .......................................... to Construct or,Repair,. ) an Individual SevCre Disposal S(item ... .................... at ................................................. No................... -,JStreet as shovin'on the application for Disposal Works Construction' Permit No.. ......"t-%Dated.._. . sz. ........... ................................. .............. ------------------------ C.V Prid ig— DATE.............-5 P .......... -------------------------------- .-FORM 1255' A. M. SULKIN, INC., BOSTON No.(i-z Fmc............................. THE COMMONWEALTH OF LSSACHUSETTS BOARD OF HEALTH ...............................__......OF.......................................................................................... Appliration for Elhipaaal Workii Towarurtion Vrrmit Application is hereby made 7 0 a PermitA o Construct O or Repair an Individual Sewage Dispogal S ysteni.at: tF _1Ltzc. - ........ . ................................................................................................... .. .. ... ......... L4k.r- L4ation-Add or Lot No. ............izX&n..... ............................................................................. Address ............ ................................................................................................... Installer Address Type of Building Size Lot............................Sq. feet U S. Dwelling—No. of Bedrooms___.........................................Expansion Attic Garbage Grinder ( PLO Other—Type of Building ....... No. of persons......S................ Showers �e— Cafeteria ( P4Other fixtures ......................................................................I............................................................................... gallons per person per day. Total daily flow............................................gallons. ---------------------------------------- Liquid'capacity.PO.P.gallons Length................ Width.,S...0... Diameter.-._--__--__---- Depth_tm_'cP. Disposal Trench—No..................... Width.................... Total Length.__................. Total leaching area...................sq. f t. Seepage Pit No.--___-_---- _-... Diameter.................... Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Per-formed by.......................................................................... Date........................................ Test Pit No. 1---_-----------minutesperinch Depth of Test Pit____________________ Depth to ground water..._.........._....__... Test Pit No. 2................minutes per inch Depth of Test Pit................_... Depth to ground water..__._......_......____. IY4 --------------e-------- ---------------*......*---------------------- ------------*--------------***------------------------ "- --------- 0 Description of Soil... -) ec, S=1C4.4V1A............ ........................................................................................................ -----------------------------------------*--------------------------------------------------------------------------*................................................................... .............................................................................................................................................................................................;0........ U Nature.of JZep Alterations—Ans er when applicable.--JeAMAZI airs Qr 9 ...4.4.0v........ .......... ..........t [/, - ................................................................ ............ 7,..... i,<.701161V.................... ---------------- Agreement: The undersigned agrees to install the aforedescribed..Individual Sewage Disposal System in accordance with the provisions of TLITMIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ii sued by th� and of IA'th. g e ne ..... . ........ .... Application Approved By....... ------- ... ................ . .............................................. .... fit' e Date 0 i g re sons.................. Application Disapproved f the ollowing reasons:............................................................................................................... ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued_....................................................... Date cez No.........- FEB........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..............................I........I.,.......I........I............................ Appfiration for Dhipatial Vorkg Tonstrurtilin ranfit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System r . .................................................................................................. or Lot No. Owner Address ................. l .................................................................................................. Installer Address y Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms Expansioil.Attic Ga;ba e Grinder ( 0�4 Other—Type of Building .... No. of persons______Z__________________ Showers Cafeteria ( 4 P4 Other fixtures .......................................... ----------------- ....... ................ ............................................................. -s w...........................:..... gallons per person per day. Total daily W �_WA ,flow............................................gtoy 04 —Liquid capacity.R......gallons Length................ Width Diameter__._.__......... DeWJL,.-4v........ Disposal Trench—No. .................... Width.................... Total Length.....iW�''Total leaching area------fflopll�-----sq. ft. Seepage Pit No--------------------- Diameter........_....__..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank aPercolation Test Results Performed by.......................................................................... Date------------------------------------.... Test Pit No. 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._....................._ ------a.. ................................................................................................... 0 <3 .w .............. --- .................................................................................................Description of Soil....s •� -C U ....................................................................................................................................................................................................... ------------------------------------------------------------------------------------------------------------- ......Ail i............ ..X------------A------------ ----------- —----- J �epairs yr It tio s— pwer w en a U Na of A qra n An' h iplicable.... -- ------- --------- J0......... ------------------------------------------------------------- ....be-CI&AA............1%W1 .5.......... .........13 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT 1Z 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been Aissued by t board health. d'.. . . ... .. ....... --------- Application Approved By.... ........1/' ....................... ... .. ..... ........................................ ........................................ all Date Application Disapproved for the following reasons:'it............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (Intifiratr of Tompliana &A".1770- - RTIFYI That he IndividuaVlew ge Disposal System constructed or Repaired by . . ..... --- ........................................................................................,47.t,-1 ler at.......................... ... ............................................................................................................... ........................ has been installed i accordance with the provisions of TleZ,& 97ahe State Sanitary 'bed in the application for Disposal Works Construction Permit No_______________________________________ ated-.........I..................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO'NST AS A GUARANTEE THAT THE t RTIFY, T------------------- ---- ------------- 1 accordance m ed rNAS ST SYSTEM WILI,� NCTION SATISFACTORY. ........................................................ Inspector......... .... .................................................................. DATE._..:�_ S THE COMMONWEALTH OF MASSA HUSETTS BOARD OF HEALTH 76 0 F No......................... FEE........................ Elispau . Work on r tion anti Pemi io Anl��e;reb zante4—rT�_ ....... ___12 ............................................................ r ?.,- ---z;;-------- a .....K is t to CP Co u ..... --- Street „ ........... ..................... em -------------- ----- -- - at No. .................................. ......................................................... �o/r' , &-- ---- as shown on the application Disposal Works Construction Permit No �ai�e .. ..... ............................... .............................. ...... ------------r....................................... Board f Health DATE-------......................................................................... o FORM 1255 HOBBS & WARREN. INC., PUBLISHERS