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Home My WebLink About0084 KELLEY ROAD - Health ` 84 Kelley Road _ - F - Hyannis. F R xd' A : �Z y r a r' - o I� Y � p u r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis Ma 02601 4/26/2010 every 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: A. General Information When filling out forms on the computer,use 1. Inspector: \ only the tab key v to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 163 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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 15.340-9f Title 5 (310 CMR 15.000). The system: Y.a ® Passes ❑ Conditionally Passes ❑ Fails ,F5 ca ❑ Needs Further Evaluation by the Local Approving Authority =�~ 2C 4/26/2010 �- Ins cto 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. nSystem t5ins-09/08 r Title 5 Official Inspection Form:Subsurface S age Dige 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis Ma 02601 4/26/2010 every 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: ® 1 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 septic system is in proper working order at the present time. 13) 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-09/08 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 ,. 84 Kelley Rd. Property Address _ Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is Hyannis `Ma,, 02601 4/26/2010 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) - 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 r ; 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•09/08 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 84 Kelley Rd. , Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis 'Ma 02601 4/26/2010 every 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 aseptic 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: TV **This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters % due to an overloaded or clogged SAS or cesspool , El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•09/08 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 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is Hyannis Ma 02601 4/26/2010 required for H y , every 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: --E] ® 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 Ell N 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. s For large systems, you must indicate either"yes"or"no"to each of the following, in addition to ther questions in Section D. Yes No i M ❑ ❑ 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 i M 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-09/08 I 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 ,M 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis Ma 02601 4/26/2010 every 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. ❑ ® 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis Ma 02601 4/26/2010 every page. City/Town State - Zip Code Date of Inspection D. System Information ` Description: System consists of a 1000 gallon tank,D-Box and two 500 gallon drywells. Number of current'residents: 7 Does residence have a garbage grinder? . ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 =ears usage d ' NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No ' Last date of occupancy: Unknown 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 . I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No a Water meter readings, if available: t5ins•09/08 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 M 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis Ma 02601 4/26/2010 every page. City/Town 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: 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis Ma 02601 4/26/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well•or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage; etc.): Joints appear tight.No evidence of leakage.system vented through the house vents. Septic Tank (locate on site plan): 10.. Depth below grade: 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 gallon 5" Sludge depth: t5ins-09/08 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 84 Kelley Rd. Property Address Bank*owned,Jeanne Durgin Realtor . Owner Owner's Name information is H annis Ma 02601 4/26/2010 required for y every 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 baffle27". 6" Scum thickness , 4„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Measured 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 is in need of pumping.Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. f 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis Ma 02601 4/26/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis Ma 02601 4/26/2010 every page. City/Town 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 No 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.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. i Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 84 Kelley Rd. Property Address :- Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis Ma 02601 4/26/2010 - every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits_ , ' number: ® - leaching chambers number: 2 ' ❑ leach ing'gaIleries ' number: leaching.trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Drywells were empty at time of inspection.Stain line ' observed 14" below invert. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13.of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for -Hyannis annis Ma 02601 4/26/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I, t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 ,map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ■ ■ Zoom OutJ11111111in "1 r K r y Fn R ��, t. 9 r� ✓} f�. P7 fY 0 2O Fie R 4 Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER :.....,.. ........... J (`—Mnhf )N1Q_9Mn Tnum of Pamefohla KAA All rinhfe recant, httn-//f(201.95.21fi/arcimc/anngenann/man.a-,nx?nrnnertvTT)=292055Rcmannsrhack= 40.7/2010 i_ Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for,Voluntary Assessments w 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is Hyannis Ma '02601 4/26/2010 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: G ® Check Slope ® Surface water ' ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 40' feet Please indicate all methods used to determine the high ground water elevation: t ❑ 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts d ' Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 84 Kelley Rd. Property Address Bank owned,Jeanne Durgin Realtor Owner Owner's Name information is required for Hyannis Ma 02601 4/26/2010 every page. City/Town State 'Zip Code Date of Inspection E. Report Completeness Checklist ` ® Inspection Summary: A,B, C, D, or checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed r ® System information—Estimated depth to high groundwater •® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file . f , j t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ® D)11LL`Lir�J.jui�l ru ca IT . • OFFICIAL _ I ru Postage $ \�CJ r=1 Certified Fee 1uPos_tmar�009 '� O Return Receipt Fee Her p (Endorsement Required) O Restricted Delivery Fee - C3 (Endorsement Required) fU p Total Postage&Fees i$ m C3 Sent o (� . ....... ' � � 3`treet,Apt.No.j - • f or PO Box No. ---� ory,s a� � i•G 5 ��0 :rr rr. Certified Mail Provides: • A mailing receipt • A unique identifier for your mailpiece i ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mall®. • Certified Mail is not available for any class of International mall. i • NO INSURANCE COVERAGE IS PROVIDED with Certified Mall. For valuables,please consider Insured or Registered Mail. • For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mallpiece*Return Receipt Requested".To receive a fee waiver for duplicdate return receipt,a USPSO postmark on your Certified Mall receipt Is rva ■ For an additional fee, delivery may be restricted to the addressee'or addressee's authorized agent.Advise the clerk or mark the mallplece with the endorsement"Restricted Delivery. Il • If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry'.''` PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signa item 4 if Restricted Delivery is desired. Agent ■ Print your name and address on the reverse X Addressee so twat we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. 7d D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No Ko dbir e-1 %A. M o PTO A Ll y o W , ?>LUE&" sr. own f-iL� S 3 viceType Certified Mall ❑Express Mail 46030 ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article"umber ' f"7007' 3220 � bjP3429 . 6264 (Transfer from service label) PS Form 3811,Febniary 2004 (� `Dome§tic Return Receipt 102595-02-M-1540 UNITED STATES PS,Q J �x .a,^,: ' "Fig ss WV6.i �.. Y I ��`�` .F:..`+.. �_��a:.Y � T 'ti::'ti tl::... �.sr✓n�d:,;y, �Et5T11;�Q�C;i J�}"iNu ' - '' .. ,.,,w,ay., n.:+•�vu..' x ,a...,.,.,,�.. �mar... I • Sender: Please print your name address, and ZIP+4 in this box • I , I Town of Barnstable{� I �. °�_ .—Health Division 200.Main Street Hyannis,MA 02601 ' .It1,,,,,I,l'�Li,�fi►,;„�'Ii►i,�tlf,�,li,,,,;lrlli„�11,,,,1,1,1 . 1 I MIKE r, Town of Barnstable Barnstable Regulatory Services Department a0-a�,Mcacnv • QARNSTABLE, 9 MASS.q 'Public Health Division m MAC a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL 7007 3020 0001 3429 8264 July 7, 2009 kobert H. Morton 440 W. Bluebird St. Gardner, KS 66030 . NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 84 Kelley Rd., Hyannis was inspected on June 15, 2009 by Jaime Cabot, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.500— Owner's Responsibility to Maintain Structural Elements: The brick step is damaged. 105 CMR 410.351- Owner's installation and Maintenance responsibilities. Exposed wiring in Bathroom. 105 CMR 410.482 — Smoke Detectors and Carbon Monoxide Alarms CO detectors missing from bedrooms. The following violations of the Town of Barnstable Code were observed: 1� 70-4—Certificate of Registration. Rental property is not registered with Town of Barnstable Health Department. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by installing smoke detectors in accordance with Mass Fire.Codes. You are directed to correct the violations listed above within thirty(30) days of your receipt of this notice by registering the rental property with the Health Department, repairing the damaged step and correcting the wiring violation. 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 days failure to comply with an orders 1 constitute a separate violation. Should you have any qu tions regarding the above violations, please contact the Town Health D 'sion as to speak with the.inspector who performed the inspection. �A&ER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable FxR.M80 C&W HOBBSB WARRENrm THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH p.,(Z STL1,4ra L f� CITY/TOWN o D_EP•AARTMENT�p °� —�1��_lam NT �Z�f✓/�' wN Svey.�o- AD RESS T � -�ON Address t N Occupan LFuA �ttL-�-� ►-+ Floor Apartmeno. �— No. of Occupants �_C,15 /)Za c,ys + 4FC9zS No.of Ha itable Rooms 5- No.Sleeping Rooms_3 C-�IILoREN ,IJ S Z` No.dwelling or rooming units No.Stories U Name and addressofowner aA'T�*� ��S,p,S 6�jQ Remarks � Reg. Vio. YARD - Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: '(_V_ w� Z Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: --r£tiQ Dampness: �,, Stairs: Ling dn/ Li htin : 2 T3I2S STRUCTURE INT. Hall,Stairway: NJQ -C FiC-1co ZF10 4 E Obst'n.: CMc3�ts -t (4�1\91Vtra Hall, Floor,Wall,Ceilin : (�.AS4_,-Ae Hall Lighting: US t., Ic %..j 4 e, Hall Windows: 11 HEATING Chimneys: Central ❑ N E u'i . Repair TYPE: tacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P ol Waste Line: H.W.Tanks Safety and Vent(s) EL RICAL 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 O% 17 l„�, ►21n+ h► A N \. AL Pantry Den Living Room Bedroom(1)- Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink (> Ll S( C- L@P® PA I Stove to -! bz � Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: jl�kj 2- �t2a i N\ Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: " (D General Building Posted L 'k 12f - , Igo-Lj/ Locks on Doo .J •- tA%-Tc R to 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 F PERJU Y " INSPECTOR+ 2�• TITLE S nY,e-1oIL DATE CO / UO�I TIME �•` ?JU P.M. A.M. THE NEXT SCHEDULED REINSPECTION -T&C1 P.M. . - ` ^ ^ ' 410.750 Conditions Deemed VxE d | ' p i f1oakh or Safety The following conditions, to be �h � impair thehealth, ox ' und -�b� �� r ~ ��^ � ouo�p�ng�� '- �o�� Th�|�m~-�onm ' cd- domow�oh�edoo�od ` ^� ' �oakwaynhave*mpotanhalk/ondongorovmoterial|yimpairUhohmddhocoafety. andwmU'boingof\ho occupants ox the public. Because Chapter||. 1O5CMR41O.10O through 41O.620 state minimum mquimme�tsoff itn000hx human . i haUi�-hon. anyotho,vio�tionhas the potential to fall within this category in given specific situation but may n�d000 n ndhoi �i� _ d� this listing. Fui| �oi | dh || i boi � � o� ��e,minohnn�ha�� Nmo�|��i�u��d�� ^� \ -'- '--�--- --� -�-'-' '-�- - h - --'� --`~~�~ '� . UoaU�o��|to order mpa/roroon0000n of such violation(s) pursuant to 105 C�R 410.830mmugh 410.833 nor shall failure Vo � 1 include affect the legal ��d`opo�onko whom the ordmio� � issued with ord er. ^ ' (A) Failure toprovide a supplyof water sulficient in quantity�-bressureand temperature, both hotand'^ d.�mee��i��^ ! noodgof the 000upantinacoordanoowhh1O5'CMR41O�18Oand41O19O�xapohod�d24houmur|ongor. _ . ' (B) Failure to provide heat as required by 105 CWR 410.201 or improper venting or use ofospace heater m water heater as prohibited by1O5 CIVIR41O�2OO(B)and 41O�2O2.. ' . � (C) Shutoff and/or failure to restore electricity or gas. (D) Failure Um provide the electrical facilities required.by1O5CWR41O.250(B). 41O.251(A). 41O.253 and the lighting in com- mon oeuequimd by 105CIVIR410.254 � (B Failure topnm�ouua�oupp��wa�r� . ' . . . (F), Failure to provide a toilet and maintain s sewage disposal system in operable condition as required by 105 CMR ' 41O15U(A)(1)and 41O�3OO. . . - � ^ `(3) F�|�m adoquateoxito, mUhaobotruohonofany exit, passageway -' area caused~ by any �-'.. . � including garbage ortraoh.vvh�h prevent egress in case of anomongon6y 1O5CMR 410.450. 410.451 and 410.452. � (H) Failure-to comply with the security requirements of1O5CIVIR41O.48OD>. � (|) �N m 0.601 cx410.6U2which results in any accumulation ofgar- ' h. filth u�omovoaus&u�oiohno��whio� doa�odoou��or.harbo�gn1or rodents, inuoo�opestshor pests ` pr oonVib�o�oaoo�o��or0o the omahonorop�adofdiooaxo' (J). The presence of leodbanod paint ,n s dwellin6 ordwo|iog unit in violation of the Massachusetts Department of Public � Health Rogulahono for-Lead Poisoning Prevention and Control, 105CIVIR460.000. (See W£Lo. 111 @@ 10O through 189.) - , _(K)' Roof, foundation, or other atructunddo�eots that may expose the occupant m anyone else Vb fire, burns,shock, aooidohtor ` � other dangonu or impairment to baddh or safety. � -(U Rai|umVo install electrical, plumbing, heating and gas-burning facilities 6a000r 'danoowiUha000 plumbing, heating, ' gas-fitting and'elooti�i6al wiring standards nr failure 0o maintain ouoh'hmi|hoomu are required by105CMR41O.351 and 41O.352. | ooao10 expose tho'000uponUm anyone else Vohm. bur�s. ohook. accident mc4hm danger or impairment Vx health orna�� | ' _ . . , (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 orwhich may result inthe release of powdered, crumbled or pulverized asbestos material in violation of1O5 . | C�R41O.353. ~ (w) Failure to provide a smoke detector reqjirod by 105 CIVIR 410i482 ([) Any of the following conditions which,remain uncorrected for a period of five or more days- following thonoUoomor |_ knmWodgocdth��w�mdooidoond�on�vcond�ono� ' - - | _ (1)_ Lack cfa��hon�nk��au#�en size and hnwashing d�hooand khchonu�nu� � st ove . . / m any dn�o �hskm�donoodhorinopom�e� . ' -(2) Failure to provide u washbasin and shower ox bathtub uo required in1O5CMR41O.15O(�)(2)and 41[i15OK\ CBorony ! defect which mndoro them inoperable. .' _ (3) Any defect in the electrical, plumbing m heating system which_makes such system m any part thereof inv�|ahonof ' | generally plumbing, heating,gas fitting, ux�on�iu� wiring standards not immediate hozord� . _- -- - . ' . (4) balcony, roof or similar place as ' FORM30 C&w HOBBSS WARREN T� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH SZtS L� CITY/TOWN a DEPARTMENT ' SV•>•` AD RESS Vf LL F—y � , TELEPHON9 Address . 1—Occupant_-��0 �t£L� N Floor Apartment No. �=No.of Occupants �JLti,su.. No.of Ha it able Rooms S No.Sleeping Rooms_3 _ �LILRf,�j No. dwelling or rooming units No.Stories 2� f Name and address of owner_�j g��L't NL--"a xT0�J C� , _�- i2 �/_�,5db) y'" �b �Nf-0 lA Q- VA.N4SAS G zo Remarks � Reg. Vio. ��03 YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage 16 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: i OF- Dampness: v.c, -� Stairs: 41 a 90 J-1-1VICI6PA.1 Lighting: LLA, 2 T3I2S STRUCTURE INT. Hall,Stairway: N0 -( 6-c'ro S. 10 2 z Obst'n.: Hall, Floor,Wall,Ceiling: S DLA f- �tr-Crc-cc,R. �� As�,,•.k� Hall Lighting: x USA h, \ wv0_K Hall Windows: yt �, HEATING Chimneys: Central ❑ N E.ui . Repair TYPE: Atacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P ' Waste Line: H.W.Tanks Safety and Vent(s) EL RICAL Panels, Meters,Cir.: 110 ❑ 220 Fusin Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT -Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom vS 10 L-o, a I r, tJ A K rLo v L.A(, Pantry Den Living Room Bedroom(1). Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink (> S( (_-0-pp A Stove �- to S oZ Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: -P6 I?-,- "�(� ; N Infestation Rats, Mice, Roaches or Other: �, � Egress Dual and Obst'n: ` .tC, General Building Posted Locks on Doo U .may -- %i'CL!z to N 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 F PERJU Y " INSPECTOR + R S. TITLE�t��Ctp2 DATE Cv ji S UO�I TIME �� 3iJ P.M. . A.M. .: THENE TSCHEDULEDREINSPECTION �T 4 P.M. ice, -•-•a- r►T-r'CAKANGES BARNSTABLE FIRST DICTDu--r ......__ G 2►7►�vtr L —c-t. -�t Cc e--Imo( '1 -{- 1 "7 0 Ic o 4 L 6.AQ oN 20 0 3 GN i {� I 5 1 cq f' i Town of Barnstable �oF s�Teti Regulatory Services BARN SrA81E , Thomas F. Geiler,Director '�A b'9 A�O� Public Health Division TFO N4A'I Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 15, 2009 Attn: Hyannis Fire Health Inspector Jaime A. Cabot, R.S. conducted a housing inspection in response to a complaint. 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): 84 Kelley Rd. Hyannis,Assessors Map- Parcel: (292-055) - Smoke etectors and CO r not provided. Jai A. Cabot, R. S. Health Inspector Q:\Order letters\Housing violations\Rental ordinance\\Fire ViolationsTIRE TEMPLATE.doc a, I �� --- TOWN OF BARNSTABLE I- LOCATION SEWAGE # �Ody 4�y VILLAGE w ASSESSOR'S MAP & LOT oZh�" CSC INSTALLER'S NAME&PHONE NO. 6e�-��f'. C��.- C60'j SEPTIC TANK CAPACITY Gttio GCA L LEACHING FACILITY: (type).R19 CaC C��'dib.+/ (size) NO.OF BEDROOMS 3 BUILDER OR R PERMTTDATE: ��Za COMPLIANCE DATE: Separation Distance Between Maximum Adjusted Groundwater le to the Bottom of Leaching Facility S� Feet Private Water Supply Well and Leaching Facility (If any wells exist / Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by A 1 S7' DI- r�6• � &2 . j say • 11 � - l+ Town of Barnstable Regulatory Services • Bnxtvsrnsr•e. ` MAS& 01 Thomas F. Geiler,Director qje 059. �0 'Fo r�r►'t" Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Designer Certification Form Date: Lj— O`- Designer: A R N C H• Q_\o�1-A Pt-S fC- Address• '70 w� C/KBE Ei•►G-1NE-�(`WG •D CC S o3 ay -oo(0 On _27/ 0%-I L-0-71 was issued a permit to install a (date) (installer) septic system at (7o Lj �� R"� based on a design I drew, (address) dated 2/-z1 /oH �I certify that the septic system referenced above was installed substantially according to the design. I certify that the septic system referenced above was installed with changes but in accordance with State & Local Regulations. Revision or certified as-built by designer to follow. OF A14 � � o moo`' ARNE H. yGm U OJALA CIVIL N No. 0792 �O S T � � G (Designer's Signature) (Af p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form TOWN OF BARNSTABLE .. LAC- LOCATION Tq SEWAGE # �Ody o�y VILLAGE Gal alf'VIT ASSESSOR'S MAP & LOT oil)- 61S3 INSTALLER'S NAME&PHONE NO. �ar-��f, ��tr✓c�iO� s/?9-89>G SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 2P Ca C CAam A-,' 40 (size) /Q'/-N"X.2" NO. OF BEDROOMS 3 u BUILDER OR R /7Jor><o PERMITDATE: 3N COMPLIANCE DATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S 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 Feet within 300 feet of leaching facility) Furnished by 7/ wV 4 Pr "PI!=.y.�� ' y w Est Q . Cc% r 7 v -4, a ZQZ No. �U r _ 4 fi Fee,.S THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Application for Migogaf �bpgtem Congtructfon Permit Application for a Permit to Construct( . )Repair(✓)Upgrade( )Abandon( ) O Complete System C"fhdividual Components Location Address or Lot No. / Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name, .Address and Tel No. /cJ Designer's Name,Address and Tel.No. 7 Type of Building: Dwelling No.of Bedrooms l3 Lot Size sq.ft. Garbage Grinder(,e)IO Other Type of Building le No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 13 ig gallons per day. Calculated daily flow 3y gallons. Plan Date Z Z/ D Number of sheets Revision Date Title e Size of Septic Tank fDDD Type of S.A.S. S� Description of Soil, Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b s B Health Signed Date Application Approved by Date ./ ttj Application Disapproved for the f owing reasons Permit No. D 0 0Y—p&:V Date Issued 3 • , .K srr� ,/ s ' c)0U'7,_g `' f j r� Fee' _ TH COMMONWEALTH OF MASSACHUSETTS Entered in computer. i/,./ ; j 'PUBLIC HEALTH DIVISION -TOWN OF BARNSTTABLs MASSACHUSETTS Yes ap pfi atton for Mtopooal *potem Congtructton Vermit Application for a Permit to Construct( . )Repair( v111Upgrade( )Abandon( ) El Complete System 21ndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. N " Assessor's Map/Parcel /le/%y ra/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,.. P , Il_ ,V D Type of Building: f i r. Dwelling No.of Bedrooms .� Lot Size�Do sq.ft. Garbage Grinder( �� Othei Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / I Design Flow 13,0 : gallons per day. Calculated daily flow 3 3b gallons. Plan Date Z Z D Number of sheets j Revision Date Title t Size of Septic Tank ,/DOO Type of S.A.S. 7_ Description of Soil 9X Z I Nature of Repairs or Alterations(Answer when applicable) ° Date last inspected: r� Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been issuedly is Board ofHealtlh Signed >'S - Date Application Approved by ate ? /tIL Application Disapproved for the fdEEwing reasons I Permit No. a n U L/ Date Issued Vf,-10 V THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY.,that the On-site Sewage Disposal System Constructed( )Repaired( tfUpgraded( ) Abandoned( )by at G i° V / r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �Ootl—0kt/ dated L/ Installer Designer 7 The issue of&s permit shall not be construed as a guarantee that the systern,will�nction -derrsi ned. Date��1 jilt Inspector 1� i ,- r f ` Q No. _0 T`� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi0pont 6pgtem onotructton Verm�tt Permission is hereby granted to Co struct( )Repair( Upgrade( )Abandon( ) System located at 4" ! 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 date of this pe ,du� Date: l D L/ Approved by ' / �� i 'i 1 FAILED INSPECTION COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS "DEPARTMENT OF ENVIRONMENTAL PROTECTION �l RECEIVED JAN 0 6 2004 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIF CATION MAP Property Address: PARCEL LOT Owner's Name: Owner's Address: Date of Inspection: __II`,'gyp K Name of Inspector• please.print) l , 425 '"T f'tC.)tC JAN 0 6' 2003 Company Name: — �. - Mailing Address: TOWN OF BARNSTABLE a 00CLO� HEALTH DEPT:, Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete.as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a D)r P approved system.inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further'Evaluation by theLocal Approving Authority Fails Inspector's Signature: ;/ ...• 1. Date: -- o2 i The system inspector shall submit"a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and-copies sent to the buyer, if applicable, and the approving authority. Notes and Comments F ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does'not address how the system Will.perform in the future under the same or different conditions of use. Title SInspection Form 6/15./2000 page 1 PaIViifI�lGdl t.t:t..l► i► t . a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM {s PART A ; CERTIFICATION (continued) F Property Address: UA • r lea _. ; Owner: Date of Inspectio Inspection Summary: Check A,B,C,D or E.%ALWAYS complete all of Section D. A. System Passes- . k a I have.not found any information which indicates that•any of the failure criteria described id 31 O:CMR~' .1. 15303 or in 310 CMR 15.304 exist.,Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes:. +' t One or more system components as described in the"Conditional Pass"section need to be replaced:or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. , Answer yes,no or not determined(Y,N,ND).in the for the following statements. If"not determined"please explain: The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is,structurally f 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 1, indicating that the tank is less than 20 years old is available, ai ND explain: ' 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. t approval of Board of Health): t broken pipe(s)are replaced obstruction is removed ' distribution box is leveled or replaced ND explain: t r • The system required pumpinb more than 4 times a year due to broken or obstructed pipe(s).The system will f ..pass inspection if(with approval of the Board of Health):. ' broken pipe(s)are replaced i obstruction is removed ND explain: 2 �t t i Page 3 of 1l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ate Owner: Date of Inspectio . Q 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 "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: Page-4 of I I f Pi OFFICIAL.INSPECTION.FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DLSPOSAL SYSTEM INSPECTION FORM" PART A CERTIFICATION(continued) • t � t Property Address:4Rf y v Owner: 3 Q Date of Ins ectio . Q,V _ I;. D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: 1 w Yet No ? 1� '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 ' Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number K t / of times.pumped i _ —✓y Any portion of the SAS,cesspool or privy is below high groundwater elevation. 1 Any portion of cesspool`or privy is within 100 feet of a surface water supply-or tributary to a surface ; I/ water supply. Any portion of a cesspool or privy is within a Zone I of a public well. ' / Any portion of a cesspool or privy.is within 50 feet of a private water supply well. 2 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, I { performed at a.DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria. are triggered.A copy of the analysis must be attached to this form.] ✓(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as N described in 31.0 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. g E. Large Systems: 1 To be considered a.large:system the system:must serve a facility with a'design flow of 10,000 gpd to.15,00.0 + gPd• You must indicate either"yes"or"no"to each of the following: g (The following criteria apply to large systems in.addition to the criteria above) 1 yes no. i 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 i 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 i significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR yf 15.304.The system owner should contact the appropriate regional office of the Department. j 1 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION-FORM CI3ECKLIST Property Address: O Owner: Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the.following: Yes No Pumping.information.was provided by the owner, occupant,or.Board of Health. Were.any of the system components pumped out in the previous two weeks? _ 'Has the system received normal flows in the previous two week period? ZHave large.volumes of water been introduced to the system recently or as part of this inspection? L1 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 breakout? ✓_ Were all system components, excluding the SAS, located on site? 1/ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of thhe baffles or tees,material of construction, dimensions,depth-of liquid,depth of sludge and depth of scum? L 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 L/ Existing information. For example, a plan-at the Board of Health. Determined in the field(if any of the failure criteria related4 to Part C is at issue approximation of distance is unacceptable).[310 CMR 15.302(3)(b)] I Page 6 of 11 ` OFFICIAL-INSPECTIOMFORM—NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION.FORM n ' PART C , (/— SYSTEM INFORMATION T f l > Property Address: Owner r ' Date of Inspection•• LOW CONDITIONS } RESIDENTIAL ti Number of bedrooms(design):3_. Number of bedrooms.(actual): 3. DESIGN flow based on 310.CvIR 15.203 (for example: 11.0 gpd x#of bedrooms): y� Number of current residents #i . Does residence have.a garbage grinder no)/.—"2& i Is laundry on a separate sewage system ( es or✓�.'�fifyes separate inspection required] Laundry,system inspected ( es or nvk f Seasonal use: (yes or �v/ ✓v f f Water meter readings; if available(last 2 years usage(gpd)): Sump pump(yes or no • t Last date of occupancy: t� /2JGt��= C��GCl✓ s COMMERCIALANDUSTRIAL Type of establishment: Desigri flow.(based on 3.10 CMR.15.203): gpd Basis of design flow(teats%persons/sgft,etc .' i Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):-_ r Water meter readings, if available: . Last date of occupancy/use: OTHER.(describe): GENERAL INFORMATION PumpingRecords 4 Source%of information: O Was system pumped as part of the inspection•(yes no �,:... �. If yes, volume pumped: gallons—'How`wis amity"pumped determined? Reason Tor pumping: TYyW_OF SYSTEM_ a ' Septic tank,distribution box,soil absorption system _Single cesspool s _Overflow.cesspools , 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 1 obtained-from system owner) _Tight.tank _Attach a copy'of the DEP.approval ]5 _Other'(describe): , t&roximate age 9f all components, date instal led(if kno)vn) and s ce f formation: Were sewage odors detected when arriving.at the site(yes or no)- AV- 6 Paee 7 of I 1 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: , Date of Inspectio BUILDING SEWER(locate on site plan/) ter Depth below grade: Materials of constriction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction liner Comments(on condition of joints,venting;evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below tirade: Material of construction:_zconcrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no): —(attach a copy of certificate) _ Dimensions: �•5 X CD �C� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: rr Distance from top of scum to top of outlet tee or baffle: 3 Distance from bottom of scum to bottom f outlet tee or baffl : !O How were dimensions determined: Comments(on pumping recommen ations inlet and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert,evid nce of leakage,etc.): 1 GREASE TRAP ocate on,site plan) d .Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage, etc.): i i 7 Page 8 of 11. t. - OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS a, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , . .SYSTEM..INFORMATION(continued) Property Address: 1 ' 1 Owner: p Date of Inspection: �;� � �' la lc"Q 3 TIGHT or,HOLDING TANK:.lam(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: t Capacity: gallons Design Flow: gallonJday Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: n Comments(condition of alarm and float switches, etc.): ' DISTRIBUTION BOX: y (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution.to.outlets equal, any evidence of solids carryover,any evidence of leakage into rout of box, etc..): 1' ado au, PUMP CHAMB ,!:4 locate on site plan) a Pumps in working order(yes or no):. Alarms in working order(yes or no): Comments(note condition of pump chamber,.condition of pumps and appurtenances, etc.): G , C r ' 4r ,t ,t ' 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: �- -Date of Inspection: (�C� SOIL ABSORPTION SYSTEM (SAS):��(locate on site plan,excavation not required) H SAS not.located explain why, Type leaching pits,number: leaching chambers,number: leaching galleries, number: leaching trenches,number, length: 1 chino 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): y Q. Cp"ye, . CESSPOOLS&(cesspool must be pumped as part of inspect i on)(]ocate 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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation,etc.): PRIVY�(locate on site plan) Materials of.construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 49 r Way , 9 Page 10 of 11 OFFICIAL•INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS �� 3 " SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM ' PART C r SYSTEM.INFORMATION(continued) 6 t y r Property Address: .' Owner: Date of In pection: - A S 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 1,00 feet. Locate where public water supply enters the building. d E 4 - *' t; 1 1 � 60, 3� a f , ar w • •' - '` Au k ' •r 11 10 Paee 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) .Property Address: za Owner: Date of`Inspection:a 3 SITE EXAM ,Slope Surface water Check cellar Shallow wells Estimated depth to ground water �6 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of desi-dn plan reviewed: Observed site(abutting property/observatio'm 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: r , ' 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: :/ G�e Lot No. Owner: /�� Address: Cpn'traCor:_ " !J r r Address: 5 �� l/6�7'y * Notes c STEP 1 Measure depth to water'table to nearest 1/10 �. ......... month/dry/Year STEP 2 Using Water-Level Range Zone and-index Weh'Map locate �• site and determine: A Appro.prlatje index OWater-level range zone ............ STEP 3 Using monthly report."Current Water Resources Conditions" determine current depth to wat-er level.-for index well .......::.. ................ I month/Year S T E° A Using Table o*f iMater-level ,Sdju3t rients for index well (STEP 2 A), current depth to water level for index.well (STEP 3), ) 'and water-level'zone (STEP 2B) f determine water-level adjustment-........................... S ED b . Estimate depth to high•water by subtracting the water- ie,vel adjustment (STEP c) prom measured depth to water level at site (STEP 1)'.......... ...........................:............................................................. ............ I 1=191-Ire 13.--Reprcjucible computafion corm. ' :` .`+„may . r� 'yi i;�y c �i 3 � � ' � � � � � � ii • 3. 8 ' F . 1- a . � i ' � � 'f h� � , � o 4 i i . `�, f . { ; . � -�;. i �2i ! 1 • _ - i �_, i J.q j f 1'e i . t ti. �;._ . ' .� �i ' � - ,I s t; .. �:•—�„ .. • ! '_ � �. ' s f i � 1 - } �. _ i S i E.• �� ' ; ` `Q /`��, .. ti, L v d .1 ��_ � , � . � � � � � --� � �� . � ---�= . a � � • _ . � � i —. y ` FORM30 H&W HosBs&WARREN'" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 9 D /Lb.,S'(A 1&L.Fz CITY/TOWN DEPARTMENT ADDRESS L4 k1;CL (t1 V-0. TELEPHONE Address Hal ',S _ Occupant L-9/y4 L,-,gLtCA_� Floor 1 Apartment No. No.of Occupants_ No.of Habitable Rooms_&-No.Sleeping Rooms No.dwelling or rooming units _ No.Stories I Name and address of owner 12c�� t log--T D Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish ^J rXV Aj'7 l® T0010 Containers: 4 2/J O v I S/oc, U r- Draina e 00 p (LL �— hAo Infestation Rats or other: /i 7 S 4 U (- STRUCTURE EXT. Steps,Stairs, Porches: /2A A.- Dual Egress:and Obst'n.: U >`1 r✓r -t4 I ti /L ❑ B ❑ F ❑ M Doors,Windows: &_ 'I w C9 F Roof A S-7A rr fC -YZrz- LLA-I I'V"3 Gutters, Drains: Walls: n• ,o vAv D/ T v vS 3 S3 Foundation: l 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.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted U g .!s X--o Z!) 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 PERDU " INSPECTOR TITLE ?02 A.M. DATE ® TIME ��` P.M. A.M. THE NEXT SCHEDULED REINSPECTION A.M. P.M. . ..'. .V:J•1. 1...,, . w.., .-t. ih. g i• .).i • _ . :v I r 410.750: Conditions Deemed to Endanger or,Impair Health or Safety 4•p The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or j 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 n this listing. Failure to include shall in no way be construed as a determination that ,s4 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 d 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 , (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 b i105 CMR 410.250 B 410.251 A 410.253 and the lighting in com- mon ` ( ) P q Y ( ), ( ), 9 9 area required by 105 CMR 410.254r (E) Failure to provide a safe supply of water. � t (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. r-_ T _, H =-•Failure to comply with the secure re uirements 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. F t (J) The presence of Ieadbased paint on a cwelling or dwelling unit in violation of the Massachusetts Department of Public F Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) a s (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. t' (M) Ariy 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. t i (N)t 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 A generally accepted plumbing, heating, gasfitbng, or electrical wiring standards that do not create an immediate hazard. "f : (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). r (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. i k d (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. # • s I l� I x TOWN OF BARNSTABLE BAR-122 Ordinance or Regulation WARNING NOTICE 1 S` Name of Offender/Mans er •- �� : ;' ... g ° / T: `r" MV/MB Re # .. v Address of Offender �' �� . ��"��' �� g- Village/State/Zip VI -1 3i ' �,. l.,c�, .- - r Business Name P - �- ~�~° x. am/. m on' ' ' J 20 /� Business Address ".` . �.�" w .�" � . . A ? e ._ Signature o.f .Enforcing' Officer Village/State/Zip VA : 1"* Loca't'ion of Of fense Enforcing Dept/Division Offense Y� t r � = saj_ r Factsb A NjX ri A . .` This will serve only as a warning. At this time no legal action has been taken. ` , ' It is the goal of Town agencies to achieve voluntary compliance of Town s °. Ordinances, Rules and Regulations., Education efforts and warning notices are 4>'"{ attempts to gain voluntary compliance. Subsequent violations will result in , appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF ,BARNSTA.BLE r LOCA-TION � C�iy CC SEWAGE # ?a-3 �3 VILLAGE_ /�(��„„j,s ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. J, .SEPTIC TANK CAPACITY G660 ai& / c -,LEACHING FACILITY:(type) ��2— (size) ®Od NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ,�,�, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I 0 � ASSESSORS MAP NO: Sc� 3, ....:. . / vZ' PARCEL NO: Dc�S 3�.�0 No.......... Fx$............._............._ .. ... . RrnStB @ HE COMMONWEALTH OF MASSACHUSETTS -� 3 BOAR®• OF HEALTH , TOWN OF.BARNSTABLE Appliratilan for llhipvii al Works Tomitrnr#inn rrntif : '.Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal Syxstem at: tS Kelly Road Hyannis ................_.... ..... ...... ---•- ..............-----------••.........-•--••.... .......................................... Location-Address or Lot No. i Donahue ......................_.......................................................................... ............................................:..................................................... -Owner Address WJ.P..Mac omb e r Jr ......................................... .................................:................................................................ . ,a J r - -• Installer Address Type of Building Size Lot......:.....................Sq. feet Dwelling--XNo. of Bedrooms.............3............................ Attic ( ) Garbage Grinder ( ) a Other—T e of Building No. of persons............................ Showers — a YP g •--.......---•-•---••---•-•• P ( ) Cafeteria ( ) Otherfixtures d ...---------•---------------------------••-•-•-•----•-.- ----------------------------------------------------................. ...-------------------- W Design Flow...............:............................gallons per person per day. Total daily flow......................._.......:............gallons. .x _ 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.......................................... Test Pit No. I................minutes per inch Depth of Test Pit.--.--.............. Depth to ground water....................--.. rZ4 Test Pit No. 2................minutes per inch Depth of.Test Pit---z.................Depth to ground water...---.................. 0 Description of Soil........................:... v D - - Sand & .Gravel ; W ••-••------------------------------------------------------------------------------------------------------------------------------- --------------------------------------...f:....... x • U. Nature of Repairs or Alterations—Answer when applicable.......:....................................................................................... 1;-l�JJO- gallon tanks 1-1�J00...gallon...leaching pit. Agreement: 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 Certificate of Compliance has boenVsuby the and of ealth. Signed . ; 8/13/92 ........ ....................... .......... .......................... . + Date Application Approved By .................. �... ... ..<a. = ....................----- . 9`Z --------------------------------- Date Application Disapproved for the following reasons: ..................:'.........':....................................................................................................... - ..............................................................'.................................---..................... _............................................................... ................. .............. Dare................ Permit No. ......-- /.-a.:. -.��.. .............. Issued .................................................. --------------- -. Date - '? 7) No..................:...... I Fas..A....3`0... :`.1 THE COMMONWEALTH OF MASSACHUSETTS A BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for 11ispoiial Works Tomitrnrtiun Errant Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 84 Kelly Road Hyannis ................---...._--...................................................................... -•--...----••--•---......-•---••--....-----.......-----•---••-••••--•--•-•-•••----..........---... Donahue Location-Address or Lot No. ---...-•...............Ow. nerr..........-••------•---••---•--••-•....... ...........---------------................ •-•Address •=-----•------••---- --•----•----•................ W J.P.Macomb�r Jr. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling xNo. of Bedrooms.............3............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .......... No. of persons............................ Showers a YP g ------------------ P ( ) -- Cafeteria ( ) Otherfixtures -----•--------------•-------••-••-•---------------•---.--------------------------------------•-•----•--------------. 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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........................................................................................................................................................................ xD--------------------------Sand &...Gx�y---1:..•----------------------•----•--------------------•-----------•---....--------.....-----•--------.._....-------------- v - - W x -------------------------•-•------•-----------••------------. ----------------•-------•-------------------------------------------------------------------------------------•-------------•----......-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --Frallon-- tank- 1-11) ?...f;_a11on...l achin-----fit. Agreement: 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 Certificate of Compliance has been sued by the oard of ealth. Signed . /..... -------------- -----�....�13�92.......... Dace Application Approved By ........ ... ........................... .?."- .3......9. . ....................................... Dace Application Disapproved for the following reasons: ..................................................................................................:.................................... ..................................................................................................................................................................--........................................... ....-----.....------------------......-- .....�. c, Dare Permit No. .........9.. ... �--/... .................... Issued ............................................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE V�Qrtifi ate Df %TtImplianre THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by........J..P.Macomber Jr. . ...................................................................................................................................................................................... Installer at ....... 4....Ke11Y...Road-..Hya.nni.s...........................................................•---....--------..........------------..........------. ............ ............... .............. has been installed in accordance with the provisions of TITLE 5 The Mate Environmental Code as described in the application for Disposal Works Construction Permit No. ........ ' ;.... ....... ........ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................... . Inspector .:. r .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q" 3 y TOWN OF BARNSTABLE � .... 3 No... ............. . FEE.............'.: Disposal Works Tunutrnrtiun rrmit Permission is hereby granted P Macomber Jr. ' J -- •---- -----•---- •-•-- to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at No..... .. x�11YRoad Hvanni ........ . --- .. -------------------------------•-•-------....------------------•------•--•-•-------------•-----•-----------------••----•......... Street Q as shown on the application for Disposal Works Construction Permit No..9a.3.._Z Dated.......................................... .....................•-•-----•/ ' DATE.-----•------------------------•---•-••--•-•--•------..................•....... \/ Board - Health FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS .alt: TOP FNDN. AT EL. 53.1' SYSTEM PROFILE TEST HOLE LAGS - -- - ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN ACCESS COVER (WATERTIGHT) TO 6" OF FINISH GRADE ENGINEER: LISA LYONS, RS / MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 49.0 WITNESS: DAVE STANTON 2" DOUBLE WASHED PEASONE DATE: 2/20/04WY, • f7RUN PIPE LEVEL EXISTING 1 QOQ FOR FIRST 2' 3' MAX. PERC. RATE _ 2 MIN/INCH GALLON SEPTIC t 48.8't* rr if 47'0 CLASS SOILS P# TANK (H- 1O ) GAS10, r r� ' BAFFLE 46.67'/11TEE -46.5' C3 fl O Cl C7 Cl L 0 46.2' 0 CD r7I 0 0 0 4' AROUND ° 6" CRUSHED STONE OR MECHANICAL 0 0 0 0 Q ELE.2 COMPACTION. (15.221 (21) MIN g' 2' O O 0 a 0 � 0 44.2' p" A 49 ' DEPTH OF FLOW = 4 ( $ % SLOPE) ( 1 % SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE LS LOCUS TEE SIZES: INLET DEPTH = 10" 7„ 10YR 3/2 = LOCATION MAP NTS OUTLET DEPTH 14" B FOUNDATION EXIST. SEPTIC TANK 27' D' BOX 17' LEACHING LS ASSESSORS MAP 292 PARCEL 55 FACILITY 5' *THE INSTALLER SHALL VERIFY THE 1OYR 5/6 LOCATIONS OF ALL UTILITIES AND ALL 19" 47.6' BUILDING SEWER OUTLETS AND ELEVATIONS PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM PERC ® C 39.2' LOT 75A LS 14,400t SO. FT. q t3' sl.o 160.00, 2.5Y 6/4 Off' APPROX. WATERLINE ry O (CONFIRM PRIOR TO 120" 39.2' EXCAVATION) 50.8 16" A 4 .4 �` `� 480 NO GROUNDWATER ENCOUNTERED NOTES: s W 52. _`\ EXIST. DWELL. + 0.1 LP + 52.3 TF = 53.1' SEPTIC DESIGN: NOT ALLOWED ) APPROXIMATE NGVD + 51.5 (GARBAGE DISPOSER IS- 1. DATUM IS 52.0 ` 48.5 EXISTING _DESIGN FLOW: BEDROOMS .( 110 GPD) = 330 GPD 2. MUNICIPAL WATER IS ____- ___ ., " PEEL 4 USE A 330 GPD DESIGN FLOW 3. MINIMUM r�iPE-P f,-i TG 6� /� r . s�.l 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 P :SEPTIC TANK: 330 GPD (? 660 rn ) = + 50.9 5. ►'INE JOINTS TO BE MADE WATERTIGHT. + 518` .5�8 .6 s2s USE A 1000 GALLON SEPTIC TANK (RE-USE EXISTING) 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 20" 0 o LEACHING: ENVIRONMENTAL CODE TITLE V. + 52.6 so.s TH SIDES: + 47.5 2(30 + 9.83) 2 (.74) - 118 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT TO BE USED FOR ANY OTHER PURPOSE. 48.9 BOTTOM: 30 x 9.83 (.74) = 218 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. TOTAL: 454 S.F. 336 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT 4 8" HOLLY USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. -` EQUAL) WITH 2.5' STONE AT SIDES, 4' AT ENDS AND 5' 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING SEPTIC SYSTEM �•Op� 9 BETWEEN UNITS La OD BENCH MARK - CORNER OF BULK HEAD � LEGEND TITLE 5 SITE PLAN (ON TOP OF WOOD) ELEV. = 52.5 48.2 10Q.0 PROPOSED SPOT ELEVATION OF 84 K ELLEY ROAD 100XO EXISTING SPOT ELEVATION IN THE TOWN OF: 100 PROPOSED CONTOUR ( HYANNIS) BARN STABLE 100 EXISTING CONTOUR PREPARED FOR: BORTOLOTTI CONSTRUCTION/MORTON 20 0 20 40 60 BOARD OF HEALTH MA SCALE: 1 " 20' DATE: FEBRUARY 21, 2004 APPROVED DATE off 508-362-4541 fax 508 362-9880 � SH OF M4S,�9 y� �N OF MS.A down cape engineering, inc. o� ARNEa � ARNE H. yes OJALA CIVIL NGINEERS o�A E LA CIVIL y No. 348 N 30792 a LAND SURVEYORS �°� o � ° � TE�`��``� 04-006 939 vain, st. yarmouth, rya 02675 0JALA, . ., P.L.S. DATE