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Home My WebLink About0155 LAFRANCE AVENUE - Health :r . 155.LaFRANCE AVE. ,HYANNIS A= f i� r a 0 0 m I 0? Commonwealth of Massachusetts -, Title 5 official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < J J a .4ye, _ Property Address Owner Owner's Name /Xlns�ec�ti�on information is A014, ✓ N14 04601 7required for every �1page. City/Town State Zip Code Date 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. ., J l 142API Important:when filling out forms A. Inspector Info mation on the computer, use only the tab -- key to move your Name of Inspector v cursor-do not use the return Company Name key. �y Company Address City/Town State aa Zip Code o- 779o TelephoneT4 mber License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the i ection was performed based on my training and experience in the proper function and maintenan of on=site sewage disposal systems. After conducting this inspection I have determined that the sy 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails In pector'I Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forrn:Subsurface Seviage Disposal System-Page 1 of 18 r Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ % �,� a► rc►ice Avg Property Address arSoh� Owner Owner's Name , information is Cy required for every 4r V,15 � od&o 9 / a o page. City/Town State Zip Code Date of Ifispedtion C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 ann. 1) Zs, 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: 2) 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): t5insp.doc•rev.V26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 cam, Commonwealth of Massachusetts ,z Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments Property Address Owner Owner's Name information is required for every . Pcl) page. City/Town State Zip Code Date of Inspec ion C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form r' Ili Subsurface Sewage Disposal System Foo m -Not for Voluntary Assessments Property Address R/So n,S Owner Owner's Name information is N ( required for every page. City/Town State Zip Code Date of Inspecti C. Inspe tion Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) 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 u , 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 Binsp.doc•rev.7126f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SS On 04rf �/�CvJ/LGQ� Property Address �1rs0 K Owner Owner's Name i required for every / nformation is 64 0�s AA Qri 01 page. City/Town State Zip Code Date of Ins ection C. Inspec ion Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 21-<S atic 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 1/2 day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ K^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 water supply ❑ [ Aell. ny portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 5?0 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.] ❑ system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ' 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments poS -2—all Property Address pea 0-so Owner 7C f Owner's Name information is required for every 9"l(441S page. City/Town State Zip Code Date of In pec n C. Inspe tion Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes N ❑ P ping in was provided by the owner, occupant, or Board of Health ❑ Were an of the system components pumped out in the previous two weeks? Y Y P P P ❑ he system received normal flows in the previous two week period? ElHave 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 en determined based on: ❑ Existing information. For example, a plan at the Board of Health. El approximation 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)] II 1 t5insp.doc-rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form iA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u Property Address G�014. Owner Owner's Name information is /%a 04 N IS �✓`l' 60 / I O� required for every - — page. City/Town State Zip Code Date of Irlspect6n D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): — Number of bedrooms(actual): J '70 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): � Description: / /00,' Us-44r I Number of current residents: — Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes information in this report.) Laundry system inspected? ❑ Yes Et5o Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? Yes No IA IGw Last date of occupancy: ate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System For -Not for Voluntary Assessments CY `..............e � 4ylG*C—. Property Address G.rsoKs Owner Owner's Name ,t� j 9 9 0/ / / Oi 0 required for every information is 1�1h� page. City/Town State Zip Code Date of I spect' n D. System Information (cont.) 2. CommercialAndustrial 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 Water treatment unit present? D Yes ❑ No If yes, discharges to: - Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes Er o If yes, volume pumped: gallons How was quantity pumped determined? -- Reason for pumping: ------ t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form f. Subsurface Sewage Disposal System For -Not for Voluntary Assessments Property Address prso v1 Owner Owner's Name ,(� l 9 information is g H N t f �/J �C7`4 O/ / / a required for every L7 page. City/Town State Zip Code Date of In ectio D. System Information (cont.) 4. Type of Syste 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): Approximate age of all components, date installed (iro, n)jnd source of information: lyiy- /7- Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: t ❑ cast iron 40 PVC ❑ other(explain): < 0 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 01 Property Address i�a/SoJ/tf Owner Owner's Name 9 information is cw4t f N'4 "e44VJ / pZO required for every —_ page. City/Town State Zip Code Date of I pect on D. Syste nformation (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet Materia 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: x Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �t� t✓t Ir10 ------ -- -- i � �s t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts ,�p Title 5 Official Inspection Form �= i= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u Property Address aisDY1-5 _ Owner Owner's Name /j/) information isHrequired for every /j f� o C� -xo a N�t� I /7 1y I page. City/Town State Zip Code Date of Wspediion D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 Nnsp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts �y Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �✓se h Owner Owner's Name L _ information is NA 0,4/ 0 required for every _ �O _ page. Cityi I own CZ2State Zip Code Date of IrApeclon D. System'Information (cost.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box(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 or out of box, etc.): �_ so t5insp.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage SSDisposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name �y information is 6164 4 fs A'4 m� / C required for every page, City/Town State Zip Code Date of Insp ction D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition'of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: cy � leaching pits number: — ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — —— 15insp.doc•rev.7/25/2018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form �I Subsurface Sewa a Disposal System F rm Not for Voluntary Assessments Property Address Owner Owner's Name 9 9 information is g fil(7/s //� G L I / V required for every - page. City/Town State Zip Code Date of Ins ection D. SysteK Information (cont.) 11. Soil Absorption System (SAS) (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): h") Ckc-/1c 77e;il" 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts n Title 5 Official Inspection Form Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments Property Address Owner Owner's Name — -` information is N 1-f required for every page. City/Town State Zip Code Date of I spe ion D. System Information (cont.) 13. 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.): t5insp.doc-rev.7f26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form +' 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address pa rson Owner Owner's Name Q N�f f �60� aO information is required for every _ _ page. City/Town State Zip Code Date cyrnspotion D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately r cv-60 PdnO 6—llnj 3 J. � t 63- 5d �3 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r Commonwealth of Massachusetts �n Title 5 Official Inspection Form += i Subsurface Sewage Disposal System Form Not for Voluntary Assessments u Property Address Owner Owner's Name ) / information is required for every page. Cityrrown State Zip Code Date of In ecti D. System nformation (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: — � feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ erved site (abutting property/observation hole within 150 feet of SAS) Checked wit I al Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must descri ho Mou established the high ground water elevation: / 0 0 � (fgh, � . �,Pi(4�L✓ o r ---- � u✓� — tI C /ova y20 t4 r S^ if Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 • <Z'\ Commonwealth of Massachusetts 9 Title 5Official Inspectio n Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is /x required for every vt l _ ��T6o j page. City/Town State Zip Code Date Insp ction E. Report tornpleteness Checklist Complete 1 applicable sections of this form inclusive of: A. I spector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1 2 3 or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 ilure Criteria)and 6 (Checklist)completed D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 18 of 18 FORM 30 C,W HOBBSS WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN o DEPARTMENT A ADDRESS yy e ,!� ,, TE_LEPHONE Address �`�Gt ,w N�"`-� Occupant Floor. Apartment No. _No.of Occupants No. of Habitable Rooms No.Sleeping Rooms _ No. dwelling or rooming units---No.Stories__ Name and address of owner Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains.- Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: 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.: — r,.,r'/ / ® k l i^s AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Looks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten., Ga il, Elect.: Stacks, Flues,Vents,Safeties: G2, Kitchen Facilities Sink s7f' , ( m Stove 6A= r+ — CGS °L 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 Q (� 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 PENALTI F PERJU INSPECTO �� ' b TITLE C DATE ` J Z / TIME 7,100 A.M. THE NEXT SCHEDULED REINSPECTtON � �_/ J P.M. .,,f.i. _,..:t;, ,:._..,,. .., ,...,...,,N_^•%a; .tA'lr, ....•. .ti. L..q.K::.� it>"'k'+ l�ba:NtrN.•.«U:;Y't`n/F a�wr .r .dv ,.Y.., «LiMf e, w'y�:�., .... .. .:n.W .t, , 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 heaith, 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 II, 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. FORM 30 � W 'HOBBSB WARREN Tan THE COMMONWEALTH OF MASSACHUSETTS _.. BOARD OF HEALTH �&. 6& CITY/� — w a +� DE PARTMENT f� ADDRESS —7 7 6 2 —� / wM 4(y (� TELEPHONE Address � _ �C �Nw`�_ j ''`"occupant g, Floor Apartment No._ _ - No.of Occupants— No.of Habitable Rooms No.Sleeping Rooms _ No.dwelling or rooming units _ No.Stories_ Name and address of owner .. Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress: and Obst'n.: , ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls.- Foundation: i r Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y . ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: ` PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: Z ❑ 110 ❑ 220 Fusing,Grncl.: d k _ B AMP: Gen.Cond. Distn . 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., Ga il, Elect.: Stacks, Flues,Vents,Safeties: cL^� r{ Kitchen Facilities Sink �f 0 OF Stove 1,%jrlS 40 r - leD:k t6,, -i W d ti Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash.Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: Generale 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 O OCCUPANT AS DETERMINED BY .105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) 0 G{, "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES FPERJU, .' INSPECTO w, TITLE DATE 7, Z TIME ' r' y�;cx'yf�r uCt'Tey. / r ' • A.M. THE NEXT SCHEDULED REINSPECTION / P.M. 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 heaith, 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 II, 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 C.MR 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 10.5 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. 0 I FORM30 C&W HOBBSBWARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 6 /-e 1� CITY/TOWN t o _ D PARTMENT ADDRESS GSM 56 y`0� 76,z o 'L J{I 6 q y q TELEPHONE 3 Address t�S L F ova t'� `t s�'� I�f_A k-� Occupant_`e, `- M pe� Floor A artment o. No. ofOccu ants / v�� I �� No.of Habitable RoomsJ No.Sleeping Rooms p -3 �('`�`�`,• J No.dwelling or rooming units ) No.Stories /.�y� �/�®, 7 j� Name and address of owner7P .eoi'C off— /"-'"" �l Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceilin Hall Lighting: Hall Windows: HEATING Chimneys'. 7SQ Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: o1w. ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: "L` d - ? ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. I Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten. as, il, Elect.: C-1 < Fire Stacks, Flues, ents,Safeties.- Kitchen Facilities Sink Stove G-r.,, 5 eea- w— oi..7 S Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub.- Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General I Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH Carr V`�```��¢ 4%4VAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE KrtvLAlcOCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY " INSPECTO �TITLE A.M. DATE �> TIME 2 ' 3-49 A.M. THE NEXT SCHEDULED REINSPECTION P.M. . ;,Ar •.•p. ._. .�•,,..�.ilfl.,-.y.. .....C. 4:-r�•,„:• ;�... .. r �. ..� ..a w...n :•i:..,a-.ur.L•rvN�„�3.tii '[�e`�'f.. a+a.x MRyi��'�✓ �.if�,ey,*+':SY�r..r ) 1,� •as, 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 heaith, 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 n other violation has the potential to fall within this category in an given specific situation but may not do so human habitation, a y p g y Y g p Y 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 An of the following conditions which remain uncorrected for a period of five or more days following the notice to or O Y 9 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. FORM 30 CI&w HOBBSB WARRED. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH " •ri^ CITY/TOWN �\ W � � o DEPARTMENT X 7 -44 c; ADDRESS .� Fy _ q! q q G1.M 5ey`e� v 6 TELEPHONE �j 3 Address 1 -s L '_ �_�"� `'��Occupant Floor Apartment 0.___""_ __. No. of Occupants— No. of Habitable Rooms— No.Sleeping Rooms__._3 T�t� ___ No. dwelling or rooming units No.Stories ,/J� /! , Name and address of owner `7�� Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: , Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: , Roof Gutters, Drains.- Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: t Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: 4 K 7$CJ Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Liner ,(�•,- ❑ MS ❑ ST ❑ P Waste Line: T�� H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: -{rf'C i err D 7 ❑ 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. as, il, Elect.: C.S v"d r-ep-S- 1 ►r Stacks, Flues, ents,Safeties: Kitchen Facilities Sink Stove irk S. rt� t ,lr�F of , S 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 CAI y;«. �� 4*114 AAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE tla f,av^;-e Kr,,,), ,OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE .CODE OR THE p 4 AUTHORIZED INSPECTOR. (See Over) 7 I - D& 3 "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY " INSPECTOR — TITLE '7 1 A.M. DATE/_�, Z� TIME / 2 • 1 A.M. THE NEXT SCHEDULED REINSPECTION P.M. 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 heaith, 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. G> TOWN OF BARNSTABLE, LOCATION /,�� / ['�< SEWAGE VILLAGEE ASSESSOR'S MAP & LOTp �70- INSTALLER'S NAME & PHONE NO.&�')&/6 aVl- , p SEPTIC TANK CAPACITY Q21I LEACHING FACILITY:(type) � _J (size) NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER r BUILDER O OWNER DATE PERMIT ISSUED: -r DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes Nj �S '�:. `� .I. � /� �c s � e � I � ..x,, � � 4 �— a 4 � r 4:� Z70 / 6 No..._........... - F�s. ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Divi-poottl Worko Tomitrurtiou ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: --.. ................................................................................. -------------•---------------------•--•-••--------------•--...--------.....----...-------------•-• Lo lion- -\ddr sst ?0 --•---•----- ----- Owner Add, ,, ; ...... .. --•G,�!'v� ��T�.1 7G f. f1�Y-- --7.._ 1 /lit.Li.43 ••--••......- Installer Address Q Type of Building Size L.of............................Sq. feet Dwelling— No. of Bedrooms............ ................................ Attic ( ) Garbage Grinder (N4 aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtur ..-_----. W Design Flow............. ............................gallons per person per day. Total daily flow................ ..............gallons. WSeptic Tank—Liquid capacity./.lAQ_gallons Length________________ Width...--. _-___---. Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length............*------ Total leaching area....................sq. ft. r Seepage Pit No---------/......... Diameter_-_--- ------- Depth below inlet.....6........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..............••--••------••---------•---------••-••----•-•-•--••--•-••-•. Date........................................ ,..a Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ (14 Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................ 0 .................. ----•----------••------••----•--•--------•-•--••------------............................................................... •-•----------- 0 Description of Soil........................................................................................................................................................................ x v ...... w UNature of Repairs or Alterations—Answer wh n applicable__/1 ___----IA!Q.�___./--.--��f...en 4- �1; 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 h ee iss ed the a d of health. Signed ----------- `- Application Approved BY .�✓�ylQ_----- -------. ..:_....:... ..... - ------�'".- J' -® -, Dace Application Disapproved for the following reasonr: ...................................... ------------------------------------------------------------- ..------. ----.-- �� Dace Permit No. "`� �Ls....�- ........... .......... ..... - Issued `�.........-- � -....---- Daze THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 5 TOWN OF BARNSTABLE Ge>rtif rate of Tontlatizin e THIS IS TO CERTI X That the Individual Sewage Disposal System constructed ( ) or Repaired by ,'c i U I.e3'/�7 `I .,U----`�---------------------------------_------ --------------------------------- at ..--------.................-------------------.......----�-- 5-----------------L,.4-f �1 - - .----- -- ----------- has been installed in accordance with the provisions of TITI.E� of The State Environmen&I Code as described in the application for Disposal Works Construction Permit No.,X-�._.�..,•. A0....t5 ------ dated P.-c...?43. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI L FUNCTION SATISFACTORY. DATE........ ..... ...! --- ------------------------------- Inspecto>�-° �.• Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH v TOWN OF BARNSTABLE No...... J FEE._.tw�:. ...... Permission is hereby granted.....................................................I............. ........................ to Construct ( ) or Repair (--<j an Individual Sewage Disposal System Street �> / as shown on the application for Disposal Works Construction Permit`` ��Dated__ DATE........... ... Board of Health �- ------=- .-Y--`��----�----�.. •-/---- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS ::;t7 Z 70 i 96 " No................_....... F>�s.. ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Diupuuttl Work.5 Tomitrnrtiun rrrmit Application is hereby made for a Permit to Construct ( ) or Repair (,X; an Individual Sewage Disposal System at: Location-Addr•ss ,.--or Lot 34 Zfj -•--•---........_.----•---•..................... --•----•------•--- ....................................... ....................... Owner Address Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............... .._..__-_-----_---._Expansion Attic ( ) Garbage Grinder (00) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixttur s -----•--•--------------------- w Design Flow______________`..._.......................gallons per person per day. Total daily flow-.-__-__-___-_-0 a..............gallons. 9 Septic Tank—Liquid capa6ty./M..galIons Length---------------- Width......---------- Diameter-----_... ..... Depth-__-___--___.._. Disposal Trench—No. .................... Width-------------------- Total Length..__--__-___r___... Total leaching area--------------------sq. ft. Seepage Pit No........./--------- Diameter...... ../�.J_----- Depth below inlet_..._...._._____ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ pl� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 04 ........................... -------•----•--••-••-•--------••---...........---•--....._--•-------------------•---............---•-•-•....--••--•--••-•--...... 0 Description of Soil....................................................................................................................................................................... x w x ••-•••-•-•-------------------------•----•--••--•••------------------------------------•••-•�---------•-s--------------------------------------------------- --- -•------ ...----------- U Nature of Repairs or Altera ions—Answer wh n applicable--.-/NS ......./DUD_�'a__%�ruV__ L/J_i- 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-bee issued/by thee board of health. Signed ----------:/....!- �J 1--------/ --------yt ........ ...... � Dace M Application Approved By -.....f/ '� -' i�....."-'r�----fir' �'. .-----S"... F4 P� Dace Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------------------ . . ------------------------------------------------------------------------------------- Dare Permit No. %---`'...i ---------..._- Issued ------- `"'--- f-3------ -'-- Date