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HomeMy WebLinkAbout0005 MASA'S PLACE - Health 5.Mases-'Place - s IHyannis,; •A�=.292 316 o o e o I n i i e e r' Commonwealth of Massachusetts u Title 5 Official Inspection Form ' I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Jt: 5 Masa's PI Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.). Inspection Summary: Check\A,B,C,D or E/always complete all of Section D A) System Passes: .;,.+`� ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: r ❑ One or more system components as described in the "Conditional Pass" section need to be + replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of'Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form id Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 5 Masa's PI Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis ' MA 02601 10-31-17- page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ' El - 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. 1.1'System*will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in'a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts =�I Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 �Fl 5 Masa's PI Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every y H annis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I 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 ❑ ® 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I I Commonwealth of Massachusetts f� Title 5 Official Inspection Form a I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 5 Masa's PI , Property Address , Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) ., Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) s Yes No , I , ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or.privy is below high ground water elevation. r ❑ ® Any.portion of cesspool or,privy is within 100 feet of a surface water supply or tributary to a surface water supply. t ❑ a•. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. [T ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. II ❑ ® 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- 310,000gpd. ` Ei ®'„' _The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. ' E) Large Systems: To be considered a large system the system must serve a facility with a design flow-of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking'water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection El., '❑ ke"a IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 L Commonwealth of Massachusetts .. Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's PI Property Address Bank Owned (Contact'David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Hyannis I MA 02601 10-31-17' required for 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 r ❑ ® 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 backup? 0, `- ❑:. '{ 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. ® El 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.doc•rev.6116 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form .Wiq Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's PI Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? r ; - ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: 10-2017Date Commercial/Industrial Flow Conditions: Type of Establishment: e9 , t- Design flow(based on 310 CMR 15.203):- Gallons per day(gpd) n . ►, Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I - � , Commonwealth of Massachusetts ,. :a=�l Title 5 Official Inspection Form =' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's PI Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: - Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ , Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the,DEP approval. ❑ Other(describe): ' t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts a=1 Title 5 Official Inspection. Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . � a� �. ! 5 Masa's PI Property Address 1' Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis. MA 02601 10-31-17 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: 2000's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): t Depth below grade: i 24"feet Material of'construction: ,, 4 , ® cast iron * ` '" ®'40 PVC' 1 ❑ other(explain): Distance from piivate`water supply well or suction line: r feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18" feet Material of construction: ® concrete ❑ metal ❑ fiberglass [],polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of.Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal , Sludge depth: , 12" t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts �+ f Title 5 Official Inspection Form ; I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's PI Property Address Bank Owned (Contact>David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis L • MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection D. c System Information cons y t ) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle • 15" How were dimensions determined? Tape 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 good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: t ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness ` w Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 1 Commonwealth of Massachusetts :a=1 .z Title 5 Official Inspection Form - N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 5 Masa's PI Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is H annis MA 02601 10-31-17 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I • - , 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts �,+ f Title 5 Official Inspection Form ,, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's PI Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every H annis ' ' . MA 02601 10-31-17 y 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Fora Il-I Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments �!. 5 Masa's PI � Property Address Bank Owned (Contact'David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ` ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ leaching galleries 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.): Good condition and emtpy at inspection with stain line at 6" off bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 , Commonwealth of Massachusetts �R7 f Title 5 Official Inspection Form lal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's PI Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 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.): a t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's PI Property Address Bank Owned (Contact David Holt @Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately '3y/ •a �f r .. 3 7 # 4 tttiii �� t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' I Subsurface Sewage Disposal System Form Not for Voluntary Assessments sp!,i 5 Masa's PI Property Address Bank Owned (Contact David'Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town : State Zip Code Date of Inspection D. System Information (cont.) Site tiam:" ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain:. ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form 0l Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4_4! 5 Masa's PI r Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f Nordileast Lead Inspectionso.. Ine, 291 i81ahi St.,EvctmM, MA 02149 Phone:6117-2I/:3-771 g Emiait: '. twflicti:stleaclirtstw al.t•ti t iVcl>'sitc�: 44"S4'4y,illt)c•tit€;s�tleitl.c���tea LETTER OF FULL INITIAL LEAD INSPECTION:COMPLI OCR Fannie Mae c/o Cityside Management Corp: 25,Sundial Ave,. Suite 4504W Manchester,N. 0310 :Dear Property owner. This letter is to certify that] inspected your property located at 5 Masas Pl.: :Unit.none,and releuant interior and exterior. common,areas, in.the City/Town'.of Hvarinis for dangerous levels of lead ar- ordin to I W CMR 4.60.7 0-of the.Regulations for Lead Poisoning Prevention aid Control,and determined that there were.no violations of the Lead Law,Massachusetts. General Laws,Chapter l] 1,section 197: The inspection was conducted,on 07f 06 /17. I also certify that'I observed no:evideitee or ig.ns th"at unauthorized deleadinb activities may have occurredin this unit or in its associated commonareas. Please be advised that Massachusetts law-requires that.only certain residential<surfaces be free of lead paint. Thus,:this letter. does not mean that your property contains no 160d paint:: The residential nremMs or d4vellini tYnit and relevant.'common areas shall:remain in compliance.4vith the requirements of the Lead Laws referenced above only as lonL as there continues.to beano neeliita,chin6ina or:flakiiik lead"mint or;other:accessible leaded rriaterials,as ton '.as co ierinRs and/or.eacAysulants fora iina an effective harrier:ov.er such natnt or other leaded.'maferials:remain::in:Place,and as>lont= as sur6ces reversed to correct lead:;haxaMs:remain reversed and securely to place. The law grants you a 30-day maintenance period to repair deteriorated;lead pauit.or:detached coverings over such paint,and to clean up:;during>iti hieh"time this Letter remains valid.The initial inspection report indicates:which:surfaces; Uan4;contain a dangerous level oHead,as well-:as.those.surfaces,if any,that-%sere c..overed upon initial inspection., The:CLPPP,authorized serial number for this I.,etter of;Full lnitial Lead Inspection Compliance is 76364004070617-5: "11lis number is tracked and unique to this address and.unit.:. DO NOT LOSE THESE::DOCUMENTS If the documents are lost;you wlll lbe required:to:have;:additional private inspector services that may cost;:you Significant amounts of tttoney.'This Letter of Full lnitial Lead litspet tiara Gampliarice is only for the address and unit number noted above. If'you change the street address, unit/apartme.nt.mitt/er or:any other r identifyin 'information pertaininS to the;;residential premises referred to to this Letterof Full initial Lead Inspection Compliance,this:Compliance Letter maybe considered null and void by the:Department of Public Health and/or a:nuuticipal health officer g Do not alter this docu.rnent in and= Ova niter.:.ing this..docuinent is frauditl:ent and:nay;endanger,the health and safety.of a chiad. +vhich may result in sit! ificant:,legal cot sequct ccs. In addition to any potential ct�it liability 4ti-ltich nta? arise as the result :of the alteration of this Letter of Coinjiliance the Massachusetts Doartmeni of Public Health's Childhood Lead Poisoning :Prevention pra�ranl.na4 seek- criminal prosecution of any person xvho alters this document after it'is ori��inally issued. i Sincerely, s Thomas Cosco 4004 07/06117 i Inspector License r Date Questions?Call the Department of Public Health at 1-806 532-9571. DO NOT LOSE THESE DOCUMENTS i Lblk-err 09 14: .. _. i Lead Inspection / Risk Assessment Report i p p page f of i� Northeast Lead Inspections,YnG 1 291`Rain St:,Everett,AIA 02144) S- 1'ttonc:i31�=2J.3-�'14) Email:�INorthem%tteadinstxetiona rigntaii.eorn Websitez tit��z�CnOPtiICIiJtiClifl.GY)Ct1 St.# Street Name StreetType Unit 5 Masas. P1 Fnone City Zip Code Hyannis v 02601 2506 Numbero'fRootns to Unit: Owner Name: Fannie Mae Property Type: Owner:Address Z 'Single Family Contact Information:: Whitne Stoddard :603-722-2573 wstoddard ci; sidecor .co1n y cr ty p Fam ily,mily #of U nits: 7. Client Name(if.difterent from:owner): Cityside Management Corp:. ❑ Candolninium #of Units Client Address: 25 Sundial Ave `Suite#5'04W Manchester,N.H. 031`03 ❑ D'ay Care; ❑ Other: e Kev Lead Column Kev. DeleadlIC Method Column Kev DelndAGMethod Column Laundry in Basemcnt? ❑'Yes F�Ko COV Covered CAP Capped SCR -Scrapedl I:n shed Space in,,Basement? ❑Yes , o V8 Vinyl Baseboard: COY Covered DIP Dipped MET Metal ENC Encapsulated REM lRenloved VR Vinyl Rep.Window. MI, Made Intact REP Replaced> MR Metal Rep.Window PRE prepared for Enc. REV Reversed` Testing Met hod'tlsed' NA NotAccessible VR/MR Vinyl/Metal Rep Window INT lntact' NC No Coating Spk Storm Frame Removed Tile- Tile.(lesfingsuggested) r-;;l ,Component,Does`Not Exist Na�S Expiration Date: DC Dropped Ceiling X-Ray Fluorescence l Model:LPA-1'- Sena!# 3260 ;Comments/-Notes: Submitted for Compliance,Evaluation El x - Floor4 I -;(level witliin builditig`6f uni.t�bding,ins'peettd)YF1001* Property.Dingrarn/Unit Labels. t C C: 1 1 t 1 t I t 1 I t j i 1 t I t' t I t t. -• �.- 1- D t t ti I II I . g D B ?- --------------------- t A(Street Side) Start Here A( Side) Start Here A(Street S,de), _ l Pb(lead)equal to or:greater than l'.0 mg/cai2 faith x-ray Fluorescence or posit ve,with N-,iiS`is`Dangerous;. XRF Calibration Recorded in Log Book ✓- Q Check off when complete Address Verified through.USPS ✓-Check off when complete i Research on Lead Related History for Address ✓ Check off when complete www'.stale.ma.us/dnh/clpptr or 800-532-9571 Tom COSCO 4004 , }'' 07/06/17 Inspector's Name License# Signature Date LURA revised 07/15 i ADDRESS: S M�s1s U PiP`"(: `--' � � �/R'1�1-�t'.S Page:2 of_LK. INSPECTION HISTORY INTERIM CONTROL Determination Risk Assessment — Y lnspeotor Name:. Lie# FN R.A..Name. Lic# Lea&Hazards? N Signature Ur ent Pb.Hazards? , Signature Comprehensive inspector Name: SC�7 Lic# Dust Taken for Risk Initial Ins ection ---`' L PFq R.A.Name:. ,Lie#. / - Signature-----F�` '� Assessment - - Signature Lead-Hazards? Visual Portion of Comp1n.itial Inspector Name: Lick Reinspection for w/Partial PCAD interim Control R.A Name:_ :Lic# Y N Signature' I IT Signature Lead Hazards. Dust Taken for Risk Addendum(add-on Inspector Name: Lic# Assessment Reins . F to Initial-Inspection) Y F $igttature N Signature' Lead:Hazards? Visual Portion of RA Name: Lie# Reinspection for Addendum as Fuli Interim Control P inspection . y inspectorName. Lic# Signature N' Signature Lead Hazards? Dust Taken fbr Risk R.A.Name: Uc# Assessment:Reins , Walk Through for F Signature Ed/Consultation Inspector Name, Lid — Signature Risk Assessment Recertificationr REINSPECTION HISTORY` Y R.A.Name: .L!c# Visual Portion of s N Signature P Ins ctor-Name: Lic# Ur ent Pb.Hazards. 9 Reacc e Reins ection p Signature Dust Taken for RA P R.A.Name: Lic# M Recertification Visual Portion of F Signature P ins ector Name: Lick — F Reins ection P F Signature POST COMPLIANCE ASSESSMENT DETERMINATIONS PCAD Inspector Name: :Lic# Dust Taken for P Reocc.Reins ection Inspector Name: ,' Lic# Y F Signature Signature Lead Hazards? pustTaken for P Fult Inspection Reocc.Reins ection 8 .inspector Name Lic#: Acting as PCAD F Y inspector Name: Lic# Signature Visuat.Portion of, Lead Hazards? N. Signature Final Reins ection P Inspector Name: Lic#" Visual Portion of F Signature PCAD Reins don p Inspector Lic#. l Visual Portion-of 1 Signature Finai:Rein ection P Inspector Name Lic# F, Dust Taken for P Inspector Name: Lic# Signature - PCAD Reins ection. F DustTaken for Final Signature Reins" o.Reoce} "P.. Inspector Name: _. Lic# T Signature Dust Taken for PC, Rein ection P❑ inspector Name:- LIc# Dust Taken for Final F Reins o Reocc .A _Inspector Name: Lic# Signature .F Signature ADDRESS: S MASAS Pl- . Ai�t.4� 3 of ; REOCCUPANCY CERTIFICATE HISTORY COMPLIANCE HISTORY(CONT.). Certificate of Certificate of Reoccu Inspector Name: .Lic# Maintained Inspector Name: `. Com lance Signature Only after Signature High/ModRisk No Work. No'Dust #rooms rule) Work=7 Dust- Certificate:of Certificate of Reoccu anc Inspector Name:. .,'Lic# Restored Com lance Inspector Name*..Lic# . Only after Signature 77 Signature High/Mod Risk Dust wipes and atith. 9 rooms rule people Certificate of Inspector Name: Lie# Certificate of Reo an Maintained Inspector Name Lic# Signature Com liance. Only after #rooms vtod Risk: Signature ( No Work—,No Dust #rooms Wile' Work=7 Dust k COMPLIANCE HISTORY Certificate of Letter of;Full Initial Restored Compliance Inspector_Name: (,osGo ,Lic# '�Q q Com Rance Inspector Name: Ui# 0 '7 0 F6T( 1 Si nature No prior history/ Signature. l Dust wipes arid,aufh. g Nos of UD people Letter ofMte im OTHER HISTORY: WAIVERS/UD Control Inspector Name; Lic#- Approved CLPPP Waiver No.prior Comp. Signature Inspector Name:- Expires in 1 yr. Attach to Come Does Signature Recertification of Interim Control Inspector Name: Li.C#: Approved CLPPP Waiver Inspector Name: Lid Expires 2 yrs from Signature Signature original Interim: Attach to Comp g Control Does Letter of Full Deleading UD/DES'Visual Con fiance InspectorName: Lic# Reins ection Inspector Name: Lick- Signature P Signature Dust wipes if.No NOLOC Issued F Reocc. Certificate of UD/DES Dust Maintained Inspector Narnet Lic# Tai;en Inspector Names- Lic# Com fiance Signature 8 Signature. FNod Work=No Dust No LOC.Issued F Work=:7.Dust UD/`DES Dust. Certificate of Taken g Inspector Names LIc# Restored Compliance Inspector Name: Lic#: F Si nature o ' Signature Dust wipes and auth. N LOC Issued UD/DES Final people Reins ection Inspector Name: Lic# P No LOC Issued F]Signature Page 4 of t EXPLANATION OF LEAD INSPECTION I RISK ASSESSMENT REPORT FORM COLUMNS This page provides general information needed to understand the lead inspection/risk assessment report.However,you should speak with the inspector/risk assessor before you start to do any work on your home. SIDE Refers to A,B,C,or D side of the building or room.See the diagram on the cover sheet.The"A"side of the building or room is the side facing the street that gives the property its address(usually,it is the front of the building).Keeping your back to this street,from the"A"side move clockwise to the"B"side on your left,the"C" side opposite you,and the"D"side to the right. Numbering is from left to right. LOCATION/ Refers to the building component(s)being tested.Some surfaces may be made up of more than one part.For SURFACE example,"Baseboard"may refer to four separate pieces of wood(one on each wall),but is still considered one surface. LEAD The actual lead result. Each surface tested must have a result recorded in the"Lead"column. •_ A number shows that the surface was tested with an XRF analyzer.A number(or average number)equal to or greater than 1.0 mg/cm''is a dangerous level of lead. • A"pos"or"neg"shows that the surface was tested with sodium sulfide."Pos'means that there is a dangerous level of lead. • "N/A"means that the inspector was not able to test the surface.Unless the owner can get a sample to test,the inspector must assume the surface contains lead and require it to be deleaded,if necessary. • "MET"or"MR"means that a metal surface was not tested and only needs to be intact,even if it is a leaded surface. However,metal handrails,metal window sills,and metal railing caps,need to be deleaded if they test equal to or greater than 1.0 mg/cm2,or is marked"N/A." • For key to abbreviations like"COV","VB","VR"or"MR","NC","Tile","DC",see the cover page. • When a component box is slashed and there are test results above and below the diagonal line,the result on the "bottom"represents results below 5 ft.and the"top"result indicates the test result above 5 ft. TYPE OF Not all lead paint must be deleaded.This column tells you IF and WHY a surface needs deleading.The deleading HAZARD standards below may not apply for Interim Controls.Speak to your risk assessor for more information. • "Mlr'circled means that the surface is a moveable/impacted surface and must be deleaded in its entirety. • "SF"circled indicates that there is a storm frame present which requires the blind stop and exterior sill be deleaded as interior moveable/impacted surfaces. • "AM'circled means that the surface is"accessible mouthable"and must be deleaded to a minimum of five feet high,four inches in from the edge or corner. • "L"circled means that the surface is loose and must,at minimum,be made intact. • If more than one choice is circled,the rules for deleading may change depending upon what method of deleading you choose.Speak to the inspector for more information. • "N/A"means the inspector was unable to determine if the surface was a lead hazard.The person doing the deleading must check this surface and follow all the rules for deleading.Speak to the inspector for more information. • If nothing is circled in the column,then it is likely the surface does not need deleading.Speak to the inspector for more information. Remember,this does not mean the entire surface is lead free,it just does not require deleading in its current condition. URG HAZ? This column is only completed during a risk assessment.A risk assessment is an evaluation of a home's suitability for Interim Control. Only a licensed risk assessor can do a risk assessment,not all Inspectors are risk assessors. If"Y"is circled,then this surface is considered an"Urgent Lead Hazard"and some type of deleading work is required to qualify for Interim Control. IC DATE The date the licensed risk assessor determines the surface meets the standards for Interim Control. IC METH The deleading method or structural repair done to qualify the surface for Interim Control.Refer to the deleading codes key on the cover page. DELEAD The date that the lead inspector reinspects the surface and finds that it has been successfully brought back into DATE compliance. DELEAD The method used to bring a surface into full compliance.Refer to codes in the Key on the cover page of the PCAD METH EXCLUDED The amount of loose paint on a surface as measured by the lead inspector."N/A"means that the inspector was not SURFACES able to measure the loose paint,but has determined it is more than the cut-off for moderate risk making intact. LIRA Exp.8/08 E I .Cos co 4004 Page Inspector(print) Lic# Signature. Date Risk Assessor(print) Lic# Signature Date Address of Property: S MASAS L Apt.#' 'City: RYAI�ulS ROOM,# SIDE LOCATIOW LEAD TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION] LEAD TYPE OF URG IC IC DE DELEAD SURFACE HAZARD HAZ DATE METH DATE METH SURFACE I HAZARD DATE METH DATE METH A B.Up Walls AIM L N/A Y A Window Silt AIM L WA Y ! A n Low Wags AIM L WA Y B Win Apron AIM L NIA Y A B Baseboards AIM L WA Y C Win Casing b A/M L NIA Y A B'Chair Rail A/M L N/A Y D Header.Stop_ M11 AIM L N/A Y° B Radiator Q �L AIM L NIA Y Int Stops Mil AIM L N1A 'Y Fkior D AIM L NIA Y Win Int Sash MA AIM L WA Y Ceiling A1M L NIA Y �? Exterior Sill Mn SF L WA Y ' 6B Door' AIM L N/A Y Part Bead` W L WA Y , C D Door Casing AIM L NIA Y 4 Blind Stop d 0 W SF L WA Y 62 Door Jamb 2 AIM L N/A Y Win Ext Sash- Mn L WA Y 3*Threshold AIM L WA Y A Window Sill' MII AIM L NIA Y Door 3 AIM L NIA Y B Win.Apron, AIM L N/A Y C D.Doorcasing AIM L WA Y C Win Casing AIM L WA Y 1 Door Jamb 2. AINI L NIA Y D Header Stop Mll, AIM L WA Y 34 Ttireiihoid AIM L WA Y Int Stops W AIM L WA Y A B:Door AIM L'.WA Y 1 Win IntSash. M11 AIM L NIA Y C D:Door Casing AIM L NIA Y 2 Exterior Sill Mn SF L NIA Y :1:2 DoorJamb AiM'L NIA Y 3 Part Bead Mll. L NIA Y 3 4 Threshold AIM L'NIA Y' 4 Blind Stop Mn :SF L N/A Y - B Door AIM L NIA Y Win Ext Sash M A L N/A Y C.D.Door Casing AIM L NIA Y A, Window Sill W AIM L N/A Y 12. Door Jamb AIM N1A Y. B. Win Apron AIM L WA. Y 3*Threshold_ AIM L NIA Y C Win Casing AIM L NIA Y • A'CiosetDoor' AIM L WA Y D Header Stop Mn A/M L N/A Y ® Cl Casing ARvi L NIA Y Int Stops W AIM L N/A Y C:GlosefJanrb p AIM L WA Y 1 Win Int Sash Mn.AIM L NIA Y D Closet Walls 3. AIM L WA Y 2 Exterior Mll SF L WA Y CfBaseboard AIM L WA Y 3 Part Bead Mil L WA Y Closet Pole 17, AIM WA Y 4 Blind Stop W SF L N/A Y Closet SheK Aq, AIM L NIA 'Y Win Ext Sash T Mll L WA Y 3 CI Supports on AIM L NIA Y AB Fireplace 9L AIM L NIA 'Y { 4 Closet Floor ivA AIM.L N/A Y D Mantle b . AIM L N/A 'Y r E Closet Ceiling IN h I AIM L.N/A Y• cAB o Win Above 5' AIM L WA Y COMMENTS I STRUCTURAL DEFECTS: Ceiling Mold' AIM L WA Y 1 FX6 GAR "1IDUv8t: {Nrt� WiNDdWS A? pau6. A/M L N/A Y F AIM L WA I Y ,i fi�NNEtJ Wµpo�tF}C(S, . AIM L WAl Y SurMpqs usf in these-boxes can MY mode,intact by'a Del,pader SIDE LOCATION MEASURE:LOOSE PAINT. IC IC Cheek the bOX if this ROOM IS RULED OUT for (MORE THAN 288 SQ.IN.) DATE METHOD encapsulation because there are 3 Or more surfaces`Wlth adhes n problems and/or 3 or more loose A/M surfaces I Lt/RA RepRoom,6115 l T.Cosco 4004 L t 0 7-a b 17 Page Oda Inspectot-(print) Lit# Signature Date R*Ass (print) LIc# Signature Date Addressofprooerty :S tjdsAS P1, Apt # City: MyAwyls ROOM#,• 11 sfDEJ LOCATION/: LEADI TYPE OF URG IC IC: DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD ^SURFACE HAZARD' HAZ DATE, METH DATE, METH SURFACE' HAZARD HAM, DATE METH DATE METH. A B A/M L N/A Y Window Sir A/M L NIA Y n.A"B Low Wags A/M L N/A Y B Win Aprory -0 AIM L.NIA Y A B Baseboards A:, AAvI 1,N/A y C Win Casing ? AIM L N/A Y A B '611 r aiC A/M 4 NIA Y D Header Stop W A/M L N/A Y' R 0adiator .( AIM L N/A Y Int Stops: ( MA AIM L NIA Y Floot� .01 AIM LNIA Y Q Win Int Sash MA AIM. L N/A Y EQiling; AIM L N/A Y (1 ExtedorSilt 2 MA SF L NIA' Y I pool AN L'N1A 'Y' 3 Part Bead Mll. L NIA Y C D awCasing 0 AIM L N/A Y 4 Blind Stop p MA SF L NIA Y 2 Door Jamb. -Z A/M'L NIA Y Win Ext Sash i MA. L N/A Y 3 4 Threshold AAv1.L NIA Y A Window Sill, W AAA L N/A Y A B Door." " AIM L IA Y B Win Apron AIM L N/A Y DoorCasing AIM L NIA Y D HeaderrSto MII A/M L NIA Y �2 Door Jamb A/M L NIA Y- p $.4 Tt regtiold AIM L'N/A Y' Int Stops MA AIM L WA Y A B A/M L-NIA. Y 4 Win Int Sash MA AIM L N/A Y CD-Door Casing A/M.L NIA, Y- 2 ExtenorSli , Mn SF L NIA Y 12,DoorJamb AAN'L NIA Y 3 Part Bead MII L NIA Y -3 4.Threshold AIM L N14 Y 4 Blind Stop MA SF L NIA Y A B..Door A/M'L NIA .Y Win Ext Sash Mh L WA Y AIM,L NIA Y A Window S11 W AIM L N/A Y C.D:DoorCasing B Win Apron AIM L N/A Y 12 Door Jamb A1M L NIA Y 3 4 Threshold AIM L NIA Y C Win Casing A/M L N/A Y A Clos4pbor` AMI L NIA Y D Header'Slop, MA AIM L NIA Y CI:Casing AAN:L NIA Y IntStops w AIM L NIA Y C'Closet Jemb Z AAvt L N/A Y 1 Win Int Sash MII AAN L NIA Y D Closet Walls - S A/M L N/A Y 2 Exterior Sill M0 SF L NIA Y c(Baseboard ,� AIM L NIA Y 3 Part Bead Mli L NIA Y UC*t'Pole A/M L N/A Y 4 Blind Stop MA SF L NIA Y 2 Closet Shelf AIM L N/A Y Win ExtSash MII L NIA Y 3 CI supports d.2 AIM L N/A Y .B Fireplace A/M L NIA Y 4 Closet Floor. ( A/M L N/A Y C D ManUe AIM L NIA Y i ICoset Celiing FI A/M,L N/A Y' �p Win Above 6' A/M L NIA Y coMwNtstsTRLIcTuRALDEFIECTSi Ceiling Moldin A/M' L NIA Y E A/M L NIA Y CAM oN c40r o4j!$.j- AIM L N/A Y r A/M L NIA Y E fisted, 1n thes@- XeS`canon ybe made:intact by a eledder SIDE LOCATION~ MEASURE;LOOSE PAINT IC is Check the box if this ROOM is RULED OUT for (MORE THAN2t38$0:IN,) DATE METHOD. encapsulation because there are 3 or more Surfaces with adhesion. problems and/or 3 or more loose A/M surfaces r LT/RARepRdom,6115 T:Cosco 4004 �,,.', 0?-p 6-17 Page 7 Pr f1 Impector(print) LIc# Signature Date Risk Assessor(print) Lit# Signature Date Address of ProDertv: . M ASAS P L Apt# — City: HALLWAY:Interior # or ~ Common Hallway: Front Rear Floor#_ SIDE LOCATION/ LEAD TYPE OF URG IC IG DELEAD DELEAD SIDE LOCATION/_'LEAD TYPE OF. URGI IC 1O DELEAD DELEAD SURFACE HAZARD HAZ DATE METH DATE METH SURFACE HAZARD HAZI DATE ME-Rd DATE METH SLL q B' Up Walls s AIM L NIA Y A Closet Door AIM L N/A Y B, r Low Walls S AIM L NIA Y B CI.Casing AIM L NIA Y A 9_LLBaseboards A/M L N/A Y C Closet Jamb AIM L N/A Y I A a Chalr Rad A/M L NIA' Y D Closet Walls AIM L,NIA Y -24 V. co 1kadiator AIM L NIA Y Cl Baseboard AIM L NIA Y Floor AIM L NIA Y 1 Closet Pole A/M L N1A Y FPang AM L N/A Y 2 Closet Shelf AIM L NIA Y .Door AIM L NIA Y 3 Cl Supports AIM L N/A Y } C D Ddor Casing 'z, Aim L NIA Y 4 Closet Floor A1M L N/A Y j 02 Door Jamb AIM L N/A Y Closet Ceiling AN L-N/A Y 3 4r Threshold A/M L NIA Y A WindowSiU MA AAvf L WA Y B Door AIM L NIA Y B Win Apron AN L NIA Y' C D Door Casing 0 AIM L NIA Y C' Win Casing A/M L NIA, Y 1 e Door,Jamb r D& A/M L NIA Y D Header,Stop WI AIM L NIA Y 3 4'Threshold A/M L NIA Y Int Stops MA, AN L NIA Y A B Door AIM L NIA Y 1 Win lntSash MA AIM L NIA Y C@D Door Casing .I AIM L NIA Y 2 Exterior Sill MA SF L N/A Y )2 DoorJ&6. AIM L NIA " Y 3 PartBead WI' L WA . Y 3 4�Threshold. AIM L NIA Y 4 Blind Stop Mn SF L NIA Y AB Door 2 AIM L NIA -Y Win Ext Sash M/I L.NIA Y D Door Casing A/M L NIA Y A Window Sill M/I AIM L N/A Y 1 DoorJamb Z A/M L NIA Y B Win Apron AIM L NIA Y 3 4 Threshold AIM L N/A Y C Win Casing AIM L N/A Y p A B Door AIM L NIA Y D Header:stop MA AIM L WA Y D Doorcasing AIM L N/A Y Int Stops MA" AIM-L N/A Y Door Jamb AIM L NIA Y 1 Winlnt:Sash I., IM/I AIM L WA Y 3 Threshold AIM L NIA Y 2 Exterior Sill MA SF L NIA Y A:closet Door AIM L NIA Y 3 PartrBead IIAl L-WA Y B" CI Casing AIM L-NIA Y 4 Blind Stop MA SF L NIA Y © Closet Jamb AIM L NIA Y Win Ext Sash Mlt L rNIA Y AS { D closet walls t( A/M L NIA Y co Win Above'5' MA AN L NIA Y i Cl Baseboard b A/M L NIA Y co Ceiling Moldi MnAS r AIM L NIA Y 1 cbsge pole AIM L NIA Y I IM/I AIM L NIA Y 2 r ClosetSheif ' AIM L.N/A Y - COMMENTS!STRUCTURAL DEFECTS: © CI Supports' A/M L N/A Y 4 Closet Floor AN L NIA Y Closai ceigng AAd L NjAjr Y EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact only by a'licensed deleader., SIDE LOCATION MEASURE:LOOSE PAINT IC le Q (MORE THAN 288 SO.IN.) DATE METHoo Check the-box ff this ROOM is RULED OUT for encapsulation because there are 3 or more surfaces with adhesion problems and/or 3 or more loose AIM surfaces L"A RepHalL 6115 T.Cosco 4004. C lr— A7=d b -1 7 Page g of Inspector(print) Uc,# Signature Date Risk;Assessv(print) Uc# Signature Date Address of Property: S M As S P E. Apt.# City UY& Plj 5 SIDE LOCATION! LEAD TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/: LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD -HAZ DATE. METH DATE METH SURFACE HAZARD HAZ DATE METH DATE METH a Up Walls AIM L NIA Y aA Window.Sill Z AIM L N/A Y q e Low Waits AN L NIA Y B On Apron AIM L NIA Y AS l r _Baseboards AIM L NIA Y C Win Casing i AIM L NIA Y n s"ChairRat AIM L N/A Y D Header Stop JJZ Mil A/M L N/A Y Radiator Q AIM L,N/A Y Int Stops .0 MII AIM L NIA Y F.bar AIM L NIA Y LY Win Int Sash Mn AIM L WA Y w Cegrig AAA N/A Y 1� Exterior Sill Mil SF L N/A Y A'B"Door` L AIM L NIA Y 3 Part Bead wl L NIA Y Door Casing AIM L.NIA Y 4 Blind Stop Mli SF L N/A Y 2 Doorjamb A/M',L NIA Y WinExtSash M, L WA Y 3 4"Tlieshotd AIM L NIA Y A Window Sill M!I AIM L N/A Y ppp A B Door, '' L`NIA Y ® Win Apron. AIM L NIA Y `1J poor Casing AIM L WA Y C Win Casing 6 AIM L N/A Y 1 Doorjamb AIM7 L NIA Y D Header Stop Z, MH AIM 1 N/A Y 3 4 Threshoid AIM L NIA Y Int Stops M11 AIM L WA Y I A B,Door AIM -N/A Y �` Win Int Sash 3 Mli AIM L N/A Y CD Doorcasing AIM.L NIA Y 2 Exterior Sill _ M11 SF L N/A 'Y i 12'Doorjamb AIKL.NIA Y 3 Part Bead MII L N/A Y 3 4.Threshold AIM L NIA Y 4 Blind Stop M/I SF L NIA Y A'B'Door A/M'L NIA Y Win ExtSash MA L NIA Y C.D fkor Cashlg AIM L NIA Y A Window Sill W AIM L N/A Y 12'Door Jamb A/M L N/A Y. B Win Apron AIM L NIA Y .314 Threshold AIM.L NIA Y C Win Casing AIM L NIA Y ` A...GtosetDoor L NIA Y D Header Stop Mn AIM.L NIA Y B CI Casing :A/M:L NIA Y Int Stops Mn AIM L NIA Y In ash MII A/M L NIA Y amb AIM L NIA Y 1 Win tS C. .CtasetJ 3 ® GiOsetWalls AIM L NIA Y 2. Exterior Sill MJI SF L NIA Y CI Baseboard AIM L NIA Y 3 Part Bead MII L NIA Y 1U Closet Pole b AIM L NIA Y 4 Blind Stop Mli SF L NIA Y 2 Closet Shell AIM L NIA Y, JWInExt Sash Mil L NIA Y 3 GI Supports AIM'L NIA Y A 8 Fireplace A/M L N/A Y 4 ClosetFloor A/KLJIAj Y CD Mantle A/M L NIA Y AS Closet Gelling N AIM L:N/A . Y C o Win Above,S AIM L WA Y OMMENTSI,STRUCTURAL Ceiling n9 Moldinc AIM L NIA Y GC14MO9 0hpuNaXT�;, AIM L NIA Y AIM L NIA Y SUfl IN t7vb"t2 A!M L NIA Y itst in these-boxes can only be made intact by a Deleader SIDE LOCATION MEASURE:LOOSE PAINT IC IC Check the box if this ROAM IS RULED OUT for (MORE THAN 288 SO-IN.) DATE. METHOD encapsulation because there are 3 or more surfaces with adhesion problems and/or 3 or more loose AIM surfaces LYRA kepRoom;6/i 5 T.Cosco 4004 7 —06--(Z Page-Lof- ff Inspeetor(print) Lic# Signature Date i Risk"Assessor(print) / Lic.# Signature Date Address of ProoertY: 7 �f/ GYM i�L Apt:# City: 1_S ROOM#— SIDE LOCATIOW LEAD TYPE OF URG IC IC DELEAD DELEAD, SIDE LOCATION/ LEAD TYPE OF URG IC`. IC, DELEAD DELEAD SURFACE HAZARD HAZ DATE METH DATE METH SURFACE HAZARD DATE METH DATE METH A e Up Wails AIM L N/A Y A Window Sill MA AIM L WA Y A e Low Wans AIM L WA Y g)Win Apron U AN L WA Y A B; - Baseboards 'L AIM L.NIA Y C Win Casing .i AIM L WA Y 6 Chair Ralf_ AIM L NIA Y D Header Stop Z W AIM L WA Y AB Radiator 0 .1 AIM L N/A Y IntStops Mil AIM L NIA Y Floor AIM L.NIA Y WinlntSash_ MIl AIM L.NIA .Y ='. Ceiling AIM L.WA Y` 2 Exterior Sill M/I SF L WA Y A/M L NIA Y 3 PartBead M/I L N/A Y. I C D Door Casing AIM L NIA Y 4 Blind Stop WSF L NIA Y 02 DaorJamb AIM L N/A Y Win ExtSash. Z Mn L WA Y 3 4 Threshold AIM L WA Y A Window Sill M/I AIM L NIA Y 313,pi or AIM L NIA Y. B Win Apron b AIM L WA Y CD Dooe..Casing AIM L WA Y ©Win Casing 'j A/M L NIA Y 1 *4amb A/M L NIA Y D Header Stop M/I A/M L NIA Y 3 4 Threshold AIM L N/A Y In!Stops Mll :A/M L WA Y AB. :Door. AIM L WA Y Win'IntSash p Mlt AIM L WA Y C , Door Casing AIM L NIA Y 2 Exterior Sill l M/i SF L NIA Y AQ Door Jamb` AIM L WA Y 3. Part Bead M/I L NIA Y 34 Threshold AIM L NIA Y 4 Blind Stop Mil SF 'L NIA 'Y A•B Door AIM L NIA Y Win Ext ( W L N/A Y Door Casing AIM L.NIA Y A Window Sill W AIM L N/A Y 1 Door Jamb AIM L WA Y B Win Apron AIM L WA Y 3 4.Threstrold AIM L WA Y C Win Casing A/M L N/A Y A Closet Door - AIM L WA Y D Header Stop Mfl AIM L WA Y B CtCasing. 0 AIM L WA Y IntSlops Mil AIM L WA Y C CloseWamb Z AIM L WA Y 1' Win Int Sash M/I AIM L WA Y D� Closet Walls 3� _ AIM L N/A Y '2 Exterior Sill M/I SF L WA Y Ci Baseboard - AIM L WA 'Y 3 Part Bead Mil L WA Y 1 Closet Pole e✓ AIM WA Y 4 Blind Stop M/I SF L NIA 'Y 2 Chet Shelf AIM L N/A Y Win Ext Sash M/I L WA Y Cl Supports AIM L WA Y B Fireplace AIM L N/A Y' 4 CtosetFloor AIM L WA Y CD Mantle AIM L NIA Y As Closet Celing AIM.L N/A Y Co Win Above 6 AIM L.WA Y '.COMMENTS/STRUCTURAL DEFECTS: Ceiling Moldinc AIM L N/A Y S�rDirl� O5 Aim L N/A Y ` A/M L WA Y AIM L N IAJ Y Sulftces,41teOanthese boxes can intact y:a a ea er SIDE LOCATION MEASURE:LOOSE PAINT IC IC Check the boxif this ROOM is-RULED OUT fbr (MORE 288 SO IN:)` DATE METHOD encapsulation becau$e there are 3 or more surfaces With adhesion, problems and/or 3 or more loose A/M surfaces LYRA RepRoom;6A 5 T..Cosco _ 4004 (f 7..66 %`' Page of J Inspector(print). Lic# Signature Date RlskAssessor(print) Lic# Signature Date 5/ f �` i Address of Property: Apt:# City: l-T 7'�lrlx CON TTiK(NOF ROO ( S of cocA ) N/. LEAD TYPE.OF URG IC IC. DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD HAZ? DATE "METH . DATE METH SURFACE HAZARD HA2 DATE METH DATE METH ! A B Door AIM L NIA Y Low Cab Tram AIM L N/A Y C D Door Casing A!M L WA Y AB Low Cab Door A/M L N/A Y # Door Jamb AIM.L N/A Y C D: Low Cab Wells AIM L NIA Y Threshold AIM L N/A Y # Low Cab ShIvs AIM L N/A Y AS Door AIM L N/A . Y Supports A/M L N/A Y C D Door Casing AAA L NIA : Y Drawers NM L N/A Y Door Jamb AIM L N/A Y A Window S41 Mil A/M L NIA Y Threshold AiM.L.N/A I Y B win Apron AIM L NIA Y AS Door AIM L NIA Y C Win Casing AIM L WA Y C D Door Casing AIM C-N/A Y' D Header Stop Mn AIM L N/A Y # DoorJamb AIM L'NIA Y Int Stops M11 AIM L NIA Y Threshold AN L.NIA tY # Win lntSash. Mil AIM,L.N/A Y CipsetDoor AN,L,NIA Y Exterior Sill Mli SF L N/A Y A a easing AN L N/A Y Part Bead Mn L N/A Y B` CbsetJamb . AIM L N/A Y Blind'top MA 'SF L NIA Y C Closet Wails AN L NIA Y Win Ext Sash MA L NIA Y Cl Baseboard A/M L N/A Y A Window Sill Mn AIM L NIA Y Closet Pole AIM L N/A Y B Win Apron AIM L NIA Y ; # Closet Shelf AIM NIA Y C Win Casing AIM L N/A Y (91 CI 8upporls AIM L N/A 'Y D Header Stop N" AIM L NIA Y '° Cl Drawers AIM L N/Al Y Int Stops M/I AIM L NIA Y Cl Dr Frame AIM L N/A Y # Winlnt.Sash WI AIM L NIA Y Closet Floor ` AIM'L N/A Y Exterior Sill WI SF L N/A Y Closet Ceiling AIM L.NIA Y' Part Bead Mll L N/A Y AS, Sh.Ns Above 5' AIhA_L NIA Y Blind Stop Mn SF L N/A Y cb cco Mll p Gab Above 5' AIM L.NIA Y Win.Ext Sash L N/A Y A p Cab Above 5' AIM L N/A Y AB. Fireplaos A/M L N/A Y A B Up Cab Frame AIM L NIA Y CD Mantel AIM L NIA Y C D Up.Cab'Door A/M L N/A Y', AB: Sidelight(L) AIM L NIA Y Up Cab Walls AIM L'NIA Y GO Sidelight(R) A/M L N/A Y # Up Cab Shies A/M L NIA Y" c o Win Above 6 A/M L NIA Y AS Supports: A/M:L.N/A I Y CD Wm Above`5' A/M`L NIA Y ! COMMENTS]STRUCTURAL DEFECTS: COMMENTS/STRUCTURAL DEFECTS: i t ! EXCI UDED SURFACES:.Surfaceslisted in r these boxes can be.made intact only by a licensed deleader. I SIDE LOCATION MEASURE:LOOSE PAINT IC IC Check the box.if this ROOM is RULED OUT for encapsulation because 1 l (MORE THAN 288 SQ.IN.) DATE METHOD there are 31:ormore.surfaces with adhesion problems and/or 3 or more loose AIM surfaces LtJRA RepRoomCon.,6115 T.Coto I. 4004 — rid,:a 6 7 0 6 6 7 Page of t Inspector(print) LIc# 'Signature Date Risk Assessor (print) UC# Signature Dale Address of Property M ASAP G Apt # _ City: BATHROOM# FSA LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC 1C' DELEAD DELEAD SURFACE HAZARD HAZ? DATE [METH DATE METH SURFACE. HAZARD HAD DATE METH' DATE METH Up Walls A/M L N/A Y Low Cab Fra AIM 'L NIA Y n Low Walls �- AIM L N/A Y A B Low Cab Door � 4 A/M L N/A Y A B Beards A/M L NIA Y C 6 Low Cab Wal AIM L NIA Y A 9 Chair Rail AIM L N/A Y Low Cab Sh A/M .L NIA Y A.8 Radiator Q AIM L NIA Y 12 Supports AIM L NIA Y Floor AIM L NIA Y 3.4 Drawer A/M L N/A Y Ceiling aL AIM L N/A Y A Window S11 �. M/I AIM L:N1A Y A Door I V AIM L N/A Y B Win.Apron A%M L N/A Y C D Door Casing AIM L N/A Y Win Casing p AIM L NIA Y 02 Door Jamb AIM L NIA Y D Header Stop MJl AIM L NIA Y 3 4 Threshold A/M L NIA Y Int Stops 3 M!I AIM L NIA 'Y A B Door AIM L N/A Y I Win Int Sash M/I AIM L N/A Y C D Door Casing A11VI L N/A Y 2 Exterior Sill IWI SF L N/A Y 1 2 DoorJamb AIM L N/A Y 3 Part Bead MII L N/A Y 34 Threshold A/M L N/A Y 4 Blind Stop o MA SF L N/A Y` A Closet Door AIM L.N/A Y Win Ext Sash (] M/I L,NIA Y' AS B Ci Casing AIM L NIA Y CD Win Above 5' NUI AIM L NA Y C Closet Jamb AIM L NIA Y AS CDCeiling Mold' WI NM L NA Y AS 0 Closet Walls AIM L NIA Y co Medicine Cab WI A/M L NA Y Cl Baseboard. AIM L NIA Y c o Wall 0/C Mn AIM L NA Y 1 Closet Pole AIM L N/A Y 0.7, WI AIM L NA Y 2 Closet.sheti A/M L NIA Y M11 A/M L NA Y` 3 Cl Supports- A/M L NIA Y MA AIM L NA Y 4closetFloor A/M L NIA Y MA AIM L NA Y' Closet Ceiling AIM L NIA Y Mll AIM C NA Y A B Up Cab Frame AIM L N/A Y Mn AIM L'NA Y' " C D..,Up Cab Door AIM L N/A Y M/1 A/M L NA Y Up Cab Walls , AIM L NIA Y Mn A/M L NA Y 12 Up CabShivs' AIM L NIA Y W.AIM L NA Y 34 Supports AIM.L N/A Y MA A/M'L NA Y i MA AIM L N/A Y • MIl AIM' L NA Y" MIi :AIM L NIA Y PNI AIM L NA Y M11 A/M'L NIA1 Y M/I AIM L NA Y ( COMMENTS I STRUCTURAL DEFECTS: COMMENTS I STRUCTURAL DEFECTS; EXCLUDED SURFACES:Surfaces listed in these can be made intactonly by a licensed deleader_ } SIDE LOCATION MEASURE:LOOSE.PAINT IC IC a(MORE THAN 288 SQ.IN.) DATE METHOD Check the box if this ROOMS RULED OUT for encapsulation because there are-3 or more surfaces with adhesion problems and/or3 or more loose.AIM surfaces d i i_URA RepBath;6/I5 T.Cosco 4004 - - a 2. o& -/ 7 Page Inspector(print) Lic# Signature Date Risk Assessor (print) Lic# Signature Date 1 Address of Proaerty: S MgSR S PL Apt.# City: BATHROOM:# SIDE LOCATION/ LEAD TYPE OF URG I& IC DELEAD,DELEAD SIDE LOCATION// J.LEAD TYPE OF URG IC IC' DELEAD 'DELEAD SURFACE HAZARD HAZ? DATE METH DATE METH SURFACE HAZARD HAZ? DATE METH DATE METH i A B UpWalis A/M 1 NIA Y Low.Cab Fra AIM L NIA Y A B Low walls AIM L NIA Y A0 Low Cab Door AIM L N/A Y A.a Baseboards _ ,Z AIM L NIA Y C D Low Cab Walls y AIM L N/A Y A B Chair Rail A/M L N/A . Y Low Cab Shty A/M.1 N/A Y 6 D Radiator Q ay' A/M L N/A Y 12 Supports AIM L NIA Y Floor AIM.L N/A Y 3 4 Drawers. AfM L NIA Y Ceiling, A/M L NIA Y A Window Sill v O Mn A/M L NIA Y Door AIM L N/A Y. B Win Apron VA/M L NIA Y C.D Door Casing AIM 1.NIA Y Q Win Casing AIM L N/A Y Door Jamb ?a AN L NIA' Y I D Header Stop M/I AIM L N/A Y 4 Threshold AIM L N/A Y Int Stops j: M/l AIM L N/A Y A 13 Door AIM L NIA Y Win int Sash W AIM L NIA Y CD Door Casing AIM L N/A Y 2 ExteriorSili Z MA SF L N/A Y 12 Door Jamb AIM L NIA Y 3 Part Bead WI L N/A Y 3 4 Threshold AIM L N/A Y 4 Blind Stop W SF L NIA Y A Closet Door AIM L NIA Y Win Ext Sash., W L N/A Y A6 B CLCasing A/M L N/A Y c o Win Abaye 5' MA AIM L NA Y C ClosetJamb AIM L NIA Y c o Ceinng Moldf MII AIM L NA Y D closetwalls AIM L N/A Y c o Medicine Cab W AIM L NA Y Cl-Baseboard A/M L.N/A Y 6 Wall OIC Mil AN L NA Y I Closet Pole AIM L NIA Y ,n qXX5pWd-o.0 MA A/M L NA Y 2 ctoset5heff A/M L NIA Y Mil AIM L NA Y 3 CI Supports A/M-L N/A Y Mli AIM L NA Y 4. Closet Floor AIM L NIA 'Y MIt AIM L NA Y Closet Ceiling AIM L N/A Y Mn AIM L NA Y B Up Cab Fra AIM L NIA: Y Mli AIM L NA Y f j C D UpCab'Door AIM L NIA Y MA A/M L NA Y j Up Cab Walls AIM L NIA Y M/f AIM L NA Y } 12 Up Cab Shivs .S A/M L NIA Y MCI AIM L NA Y 34 supporis AIM L NIA Y Mil AIM L NA Y M/I AIM L NIA Y MA AIM L NA Y Mil AIM L NIA Y tytli A/M L NA Y i Mtl AIM L NIAJ Y I IMI1 AIM L NA Y COMMENTS.[STRUCTURAL DEFECTS: COMMENTS/STRUCTURAL DEFECTS: I EXCLUDED-ISURFACES:Surfaces listed in these boxes can be made..intact only by a licensed deleader. i SIDE LOCATION MEASURE:LOOSE PAINT IC IC ED(MORE THAN 288'SO.IN,) DATE METHOD Check the box if this ROOM is RULED OUT for encapSUlation because there are 3 Or more surfaces with adhesion problems and/or 3 or more loose A/M surfaces LURA RepBath,61115 T.Cosco 4004 o•7-0 6 -d 7 Page/3 of2 Inspector(print) Lic# Signature Date 3 Risk Assessor(print) Uc Signature Date Address of ProoertY: Jr' MASA g P L ADt. City_ t-i YAV111/1-5 KITCHEN- ' SIDE LOCATION/ LEAD TYPE OF URG IC 1C DELEAD DELEAD ` SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE. HAZARD HAZ? DATE. METH DATE METH SURFACE HAZARD HAV DATE METH DATE METH A s UpWeb 0. A/M L NIA Y A Window Sill A a Low Walls AIM L NIA Y 1 NIA Y Z B Win,Apron Z AIM :L NIA Y c B Baseboards A AIM L N/A Y Win Casing AIM L NIA Y A B Chair Rail ^ A/M L N/A Y f7 d'- D Header Stop M/I A/M L WA Y Radiator 0.1 AIM L N/A Y Int Stops M/i AIM L N/A Y Floor roV AIM L N/A Y Q Win Int Sash MA A/M L NIA Y Ceiling AIM L N/A Y 2 Exterior Sill AAA SF L NIA Y Door AIM L N/A Y 3 Part Bead ` IWI L NIA Y D Door Casing .3 0A L N/A Y 4 Blind Stop MA 'SF L NIA Y Door Jamb. .l AIM L N/A Y Win Ext Sash MA L.NIA Y Threshold AIM L NIA Y A Window Sill . Mlt AIM L NIA Y Door AJM L NIA Y B Win Apron AIM L TA Y C D Door Casing AIM L N/A Y C Win Casing AIM L NIA Y 102 Door Jamb AIM L NIA Y D Header Stop M/I A/M L N Y 3 4 Threshold AIM L NIA Y Int Stops Mn AIM L NIA Y A B:Door AIM L N/A Y 1 Win Int Sash M/I AIM L N/A Y D Door Casing, - AIM L NIA Y 2,. Exterior sli M/1 SF L NIA Y Door Jamb \1 - AIM L N/A Y 3 Part Bead MA L'N/A Y 3 4 threshold AIM L N/A Y 4 Blind Stop Mp S,F L N/A Y A B Door A/M L NIA Y Win Ezt Sash MA L.N/A Y C D Door Casing AIM L NIA Y A B Up Cab Fra 3 AIM L NIA Y 12 Door Jamb AIM L N/A Y Up Cab Door •2 AIM L NIA Y 34 Threshold AIM L NIA Y Up Cab Walls A/M L N/A Y A Closet Door A/M L N/A Y. 1 2 Up Cab ShIvs 3 AN L N/A Y B CI Casing' A/M L NIA Y 34 Supports AIM L NIA Y C Closet Jamb AIM L N/A Y Low Cab FrarD AIM L N/A 'Y D Closetwals AIM L NIA Y AB Low Cab.Door '3 AIM L N/A Y Cl Baseboard AIM L NIA Y Low Cab Wal AIM L NIA Y 1 Closet Pole AIM L N/A Y Low Cab Shtvs.1,3 AN L N/A Y 2 Chet Sheaf AIM L NIA Y 12 Supports AIM L NIA Y 3 Ci Supports A/M L NIA Y 314 Drawers 3 A/M L N/A Y 4 Clow Floor A/M L NIA Y A9 o D Win Above 5 Mai A/M L;NIA Y `P: 1 Closet Ceiring AIM L N/A Y Mai AIM L NIA Y' F4 COMMENTS/STRUCTURAL DEFECTS: MA AIM L NIA Y $L4pl�tr; 'bttp�. MII AIM L N/A Y ! M/I AIM L NIA Y IWD'D , MA AIMS L NIA Y EXCLUDED SURFACES:Surfaces listed:in these boxes can be made intact only by a licensed delead,er SIDE LOCATION MEASURE:LOOSE PAINT IC IC(MORE THAN 288 80.IN;) DATE METHOD Check the box If this:ROOM.1S'RULEQ OUT for' ' encapsulation because there are 3 or more surfaces with adhesion problems and/or3 or more loose A/M surfaces 1.11RA RepKitchen,6115 'I Cosco 4004 Tyr -cam— d 7 ©6 -! 7 Page,(�+✓ inpector(print) UC# Signature Date wskAssessor (tint) U Signature Date Aadressaf%oErtv:. 5 Masers 19c. Aof 7 EXTERIOR A Side SIDF LOCATION/ LEAD TYPE OF UPG iG IC DELEA.D DELEAD SIDE LOCATIOW LEAD TYacOF URG IC IC DtLEPD DELEAD A• SURFACE HAZARD HAZ DATE ik_RH DATE METri A SURFACE ' k"ZARD DA E METH DATE METH f SUN t WA Y Window S; AW L NIA Y Comer Board o + WA Y A win Casing A'M L WA Y A Lower Trim L NIA Y window Sass AM L NJ,4 Y '} Upper Trim L WA Y Cellar Win'Sill. plPi L WA Y Win Above 5` L NIA Y Cel win Sesh 0.if AW L NIP. Y Porch Above L NJA Y Cel win Fra. �.� A+M L NIA Y (J e Storm Door AIM L WA Y SAmen Frame A>PA L WA Y I I Door AIM L NIA Y Cskr Win Sill JVI L N A y Dgot Cc^sing 'L' AIM:L WA Y A Cel'Alin Sash AJIM L RIA Y . 1 2 Da9rJamb Z; AIM L WA Y Cei Win Fr Agri t WA- Y 3,4 Threshold A/M L WA Y Saeen Frame A=r3 L NIA Y j. Kiacplate p AIM.L.N/A Y. Cei r win'sip, XU t WA Y Slotm Door AIM L NIA Y A Gel Win Sas, AAR,4 L WA Y Door ARC L.WA Y Cei Won Frame AJhi L NIA Y A.Door Casing AN L WA Y Screen Frame WAi i WA Y 1'2 Door Jamb AJNI L N:rA Y Cellar Win Siii Alibi L NIA Y 3 4 ThrsshWd -AIM L NIA Y . A Gel Win Sash A.Qri L NIA Y I(Ickpbte AIM L,NIA: Y Ce l Ylin Frame Alin L WA Y Dom Afii! NIA Y > Screen Frame, AN L WA Y 3 A Door.Casing A, AIM L WA Y Foundation v L NIA Y t 1 2-DogrJamb AIM L WA Y A Sutkhead A1i4i L NIA Y 3 4 Threshold AM L N/A Y Fences Artvi L NIA Y Wmd*S+it AJM L WA Y Shutters 2" Aid L NIA Y Win Casing U Am4 L N/A Y newel post AIM L WA Y z Window.S+sh Z. AIM L NIA Y Railing Cap AM L NSA Y Wmdow'Siil AIM L WA Y Haxsrar7 AR.i L WA Y Win Casing AIM L NIA Y A. Balusters Artri L WA Y loqWmdaw Sash �D AIM L NIA Y Lower Rai} AIt,4 L WA Y I Window SM mm L NIA Y Treads AIM L NIA Y An Win Casing JV D AIM L WA Y Risers AJM L WA Y i Window Sash AIM L WA Y Steiger AIM t WA Y ( B Lamp Post; L WA Y La Bce AJM L WA Y COMMENTS I STRUCTURAL DEFECTS: Drain Pipes Q; L NIA Y )t0fi)1bh3 GvkPANt yt , A Eiec Conduit L WA Y ' N192 Y ;" . A1M L NJA Y Excluded Surfaces;Surfaces listed in this box can be made. Soil Test Results intact;oniy by.a licensed deteader (Must be less than 400 ppm for May area/1200 ppm for bare"soil) BIDE LOCATION MEASURE:LOOSE PAINT IC IC LOCATION AREA~,.iEASUREME1vT RESULT REMED REMED A (MORE THAN.1440$Q.IN.) DATE I '7H (Square Feet) (PPM) :DATE METH. A - PiapAw A A Bare Solt Comments; A. LURP;RepExtA.:6li s T.Cosco 4004 / jam+ -1- ''` 6 7.6 6 -/7 Page )f Inspector(print) Lic# Signature Date Risk Assessor (print) Lic# Signature Date/ Address of Property S M AS AS P l_ Apt # Ci#v �lX/S EXTERIOR. B Side SIDE LOCATION/ LEAD TYPE OF URG IC' IC DELEAD DREAD SIDE LOCATIONI LEAD TYPE OF URG IC 10 DELEAD DELEAD B SURFACE HAZARD HAZ1 DATE METH DATE METH B SURFACE HAZARD HAZ DATE I METH DATE METH. Siding L N/A Y Window Sill A/M L N/A 'Y Comer Board L NIA Y I �- B Win Casing AIM L WA Y I f B LowerTrim L N/A Y # Window Sash A/M L N/A Y Upper Trim L NIA Y Cellar Win Sill 6 AIM L N/A Y Win Above 5' L N/A Y Cel Win Sash AIM L NIA Y Porch Above 5' L N/A Y #/ Cel Win Frame p AIM L N/A Y Storm Door AIM L WA Y (J i Screen Frame A/M L NIA Y Door A/M L WA Y Cellar Win Sill AIM L NIA Y j © Door Casing U' AIM L NIA Y B Ce1 Win-Sash if AIM L N/A Y 1 2 Door Jamb x A/ML NIA Y # Cel Win Frame A/M' L N/A Y 1 3 4 Threshold L AIM L.N/A: Y Screen Frame AIM L N/A Y Kidcplate AIM L NIA Y Cellar Win Sill AIM L NIA Y Storm Door AIM L N/A Y B CeI Win Sash. AIM L NIA Y Door A/M L WA Y` Cel Win Frame AIM L WA Y B Door Casing A/M L NIA Y Screen Frame AIM L N/A Y 1 2 Door Jamb A/M L N/A Y Cellar Win Sill AN L NIA Y 3 4 Threshold A/M L NIA Y B Cal Sash AIM L N/A Y Klc kplate AIM L.N/A Y # Cel Win Frame AIM L NIA Y I Door AIM L N/A Y Screen Frame A.tM L NIA Y 8 Door Casing A/M L N/A Y Foundation. L L NIA Y 1 2 Door Jamb AIM L NIA Y B Bulkhead AN L NIA Y 3 4 Threshold AIM L WA Y' Fence's AIM L NIA Y Window Sin A/M L N/A Y Shutters I AIM L N/A Y B Win.Casing A/M L NIA Y NeWel post A/M L N/A Y Window Sash AIM L NIA Y Railing Cap A/Pil L NIA Y Window sill A/M L NIA Y Handrail kM L N/A Y i B Win Casing AIM L N/A Y` B Balusters AIM L NIA Y' # Window Sash AIM L NIA Y LowerRal A/M'L N/A Y Window Sill A/M L NIA Y Treads' AIM L NIA Y B Win Casing AIM L WA 'Y Risers A1M L N/A Y # Window Sash AIM.L NIAI Y Stringer A/M L,NIA, Y B Lamp Post L WA Y Lattice AIM L WA Y i COMMENTS/STRUCTURAL DEFECTS: Drain Pipes L N/A Y (KWi- 06M. B Elec:Conduit` L N/A Y ( 00 Fill Pipe L WA Y Overhang Tri AIM L.N/A Y Excluded Surfaces:Surfaces listed;in this bacan be rnacle Soil Test Results intact only by a licensed deleader, (Must be less than 400 ppm for play area 11200 ppm for.bare soil) f RBB LOCATION- MEASURE:'LOOSE PAINT` IC IC LOCATION AREA MEASUREMENT RESUL REMED ;REMED (MORE THAN 1440 SQ.IN) DATE METH ('Square Feet) (PPM) ;DATE METH Play Area, Bare Soil t B Comments: B, I LYRA RepExtB,6/15 T.Cosco 4004 /jj, Q :6 6 Page Of L inspector(print) UP# Izlgnatdre Date Risk Assessor(print) Uc#' •Signature Date Address of Property: S SAS PL Apt:4 —- City: A 11,c l l s PORCH A BCD (circle-one) st 2nd fl 3rd fl 4th fl (circle one) SIDE LOCATION/ LEAD TYPE OF URG IC IC DELEAD:DELEAD SIDEJ LOCATION/ .LEAD TYPE OF URG IC IC DELEAD DELEAD SURFACE HAZARD HAZ DATE METH DATE METH SURFACE HAZARD. HAZ? DATE METH DATE METH AB Siding L NIA Y support clmns G AIM L N/A Y C D comer Soards L NIA Y Newel post AIM L NIA Y UpperTrim. L NIA Y Railing Cap AIM L'N/A Y i CeNng L WA Y Handrail AIM L NIA Y Joists 'L NIA Y Balusters AIM L N/A Y A Door AIM L NIA Y Lower Rail L AIM L N/A Y B Storm,boor AIM L N/A Y Treads AIM L NIA Y © Door Casing A/M.L WA Y Risers. AIM L'WA Y D DoorJamb A/M L WA Y Stringer L .AIM L NIA Y 2 Threshold AIM N/A Y Lower Walls' AIM L N/A Y 3 4 Kickplate AIM L.N/A Y ry Lattice AIM L N/A Y A Door AIM:L NIA Y Cower Trim AIM L NIA Y B Storm Door A/M L.WA Y iFloor AIM L N/A Y C Door Casing AIM I N/A Y AIM L N/A Y D Ooor.Jamb A/M L;N/A Y A/M L N/A Y 12 Threshold A/M L,NIA Y A/M L N/A Y 34 KQckplate AIM L-N/A Y A/M L NIA Y I AB Window Sill AIM L:N/A Y AIM L NIA Y CD win Casing. AIM L N/A Y AIM L N/A Y 12 Window'Sash A/M L WA Y A/M L NIA Y 3 4 Mullions AIM,.,L NIA Y AIM L NIA Y AB Window Sill AIM-L N/A Y A/M L NIA Y C D Wm Casing AIM L.N/A' Y AIM L N/A Y 12 Window`Sash AIM.L.N/A Y AIM L N/A Y 34 Mullions AIM L NIA Y AIM L WA Y A B Window Sill AIM L NIA Y AIM L WA Y C D Win Casing AIM L N/A Y AIM L NIA Y 12 Window Sash AIM L.NIA Y AIM L WA Y 34 Mullions A/tvf L NIA Y AIM L NIA Y A B Winnow Sill AIM L NIA Y AIM L N/A Y C D Win Casing AIM L NIA Y A/M L N/A Y 1,2 Window Sash AN L N/A Y„ . A/M L N/A Y 34 1 Minions AIM L.NIA Y : AIM L N/A Y COMMENTS'I STRUCTURAL'DEFECTS COMMENTS I STRUCTURAL DEFECTS; EXCLUDED SURFACES:Surfaces listed in these boxes can be made intact oniyby a licensed deleader. SIDE LOCATION MEASURE:LOOSE PAINT IC fC(MORE THAN 1440 SO.IN.) DATE METHOD Check the box if this ROOM is RULED OUT for encapsulation because there are 3 or more surfaces with adhesion problems and/or 3 or more loose AIM surfaces ONLY CONSIDER ENCAPSULANTS IF PORCH IS USED AS INTERIOR LIVING SPACE LVP,A RepPorch.6/15 T Cosc_0 4004 J' +!1-t 6 7.0 6 .- J 7 Page d pf /g Inspector(print) Uc# ignature. Date Risk Assessor (print) Lic# Signature Date Address of Property: S M AAA S !' L Apt.# City -EXTERIOR C Side SIDE LOCATION LEA TYPE OF URG IC IC DELEAD DELEAD SIDE LOCATION/ LEAD TYPE OF URG IC tG DELEAD DELEAD C SURFACE HAZARD HAZ. DATE METH DATE' METH C SURFACE` HAZARD DATE METH DATE METH Siding L NA Y Window Sill AIM L WA Y Comer Boa .0 L N/A Y C Win Casing AIM L N/A Y `C Lower Trim =' L NA Y Window Sash AIM 'L N/A Y Upper Trim Z L WA Y CellarWin,Sill AIM L N/A Y Win Above 5' r1r L,WA Y CeI Win Sash AIM L WA Y Porch Above`5' L N/A Y CeI Win Fram AIM L WA Y Storm Door A/M L NIA Y v Sc Frame AIM L NA Y Ooor AIM L N/A Y Cellar Win Silt AIM L NA Y C Door Casing AIM L N/A Y C Cel Win Sash AIM L N/A Y 1 2 DoorJamb AIM L N/A Y Cel Win Fram AIM L WA Y 3 4 Threshold AIM L N/A Y Screen Frame AIM L N/A Y "late AIM L WA Y Cellar Win Sill AIM L N/A Y. Storm Door AIM L N/A Y C Cel.Win Sash A/M L N/A Y Door AIM L NIA Y1 9 Cel Win Frame AIM L NIA Y C Door Casing AIM L WA Y Screen Frame AIM L NIA Y 1 2 Doorjamb AIM WA Y Cellar WinS11. AIM L WA Y' 3 4:Threshold A/M L WA Y C Cal Win Sash AIM L N/A Y IGdcphate' AIM L WA Y Gel Win F ' AIM L WA 'Y Door AIM L NIA Y Screen Frame AIM L WA Y C "Door Cash , AIM L WA Y Foundation- N( L WA Y 1 2 DoorJamb AIM L WA Y C Bulkhead AIM L WA Y 3•.4 Threshold. AIM L WA Y Fences AIM L WA Y WrfdowSill A/M L NIA Y Shutters` AIM L NIA Y C':Wm d"n9 N/A Y AIM L Newel post A/M L NIA Y 77 # yfuidoiv_Sash" A/M L N/A Y Railing Cap AIM L NIA Y Window Sill AIM L"WA Y Handrail AIM L:WA Y � C Win Casing A/M L.WA Y C Balusters AIM L NA Y Window Sash A/M L WA Y LowerRall. A/M L NA Y Wlntlow Sll A/M L NIA . Y Treads AIM L NIA Y C WEn Casio A/M L N/A Y g Risers A/M L WA Y • Window Sash AIM L NIA Y Stringer AIM L NIA Y , C, Lamp Posi L NIA Y Lattii Or AIM L NIA Y COMMENTSUSTRUCTURAL DEFECTS: Drain Pipes d. L WA Y C Elec Conduit L WA Y Oil Fill Pipe L WA Y Overhang Trim AIM L NIA Y E,z Uded Sulfates:Surfaces listed:in this box can be made Soil Test Results intact only by a licensed deleader (Must be less than 400 ppm for play area/1200 ppm for bare;soil) . SIDEv °'L'OCATIQN MEASURE:LOOSE PAINT IC IC LOCATION AREA MEASUREMENT RESUL1 REMED `r:REMED . C (MORE THAN 1440 SO.IN.) DATE METH' (Square Feet) (PPM) ;DATE METH_ C. Play Area C Bare Soil C Comments: C r- LYRA RepExtC,6115 T.Cosco. 4004 Page of Inspector(print) tic Signature Date .R'ssk Assessor,(print) Lid Signa ire Date Address of Prooerty S M/�s/4 P G Am. City �y At EXTERIOR. D Side SIDE LOCAnoW L EAD TYPE OR URG IC IC DE LEAD DE}E: D SIDE LOCATI* LEAD TYPE OF URG ID 1C DELEAD DELEAD D SURFACE HAZARD HAZ. DATE VEiH DATE, ME H D SURF-ACE. HA74RD HAZ DATE METH SATE METHSang L NIA Y f/ 6ow SY: : A?J L NIA Y Comer Boards, L MIA Y i} van cac Inn A'.. L N!A: Y' D Lower Tft L WA Y 'ffmd� S---b A A L NIA Y lJpperirun L WA Y CellarWin.R tvMl L N/A Y Wn Above 5' L N/A Y Q Ce_1iYn Sash. A!IM L NIA Y Por�tt Abcnre5'. L NIA Y C Nlin Fr - AJM L'NIA Y stomf Dpor "NIA Y Secs n am2 A. 1 L'UA Y Door AIM L WA' Y Cel ar J"In STl A:M, L WA Y D 'Door Casing 7k4yi L WA Y D Cat Wip.Saah A A.t L NiA Y 1 2 Daor;Jamb A/M L N/A Y Cel'r16n Frarre Arid L N/A Y 3 4 Threshold AN L N/A Y Scree,firm= AM L WA Y i Kikkglate AIM L WA Y Cellar Win SHl AM L N/A Y Storm Door AIM L N/A Y D Cel Win Sash ` AV L NtA Y Door AIM L NIA Y Ce(Win Frame A.W .L WA Y D. Door Casing A/M L NIA Y Seen Fearie A+M L N/A Y' 1 2 Door 'Jamb , A/M L NIA Y Cei rft Siol 1>hA L NIA Y 3.4 Thrpo* AK L N/A Y D- Cal Win Sash AN WA Y _. Kidlsta AIM,L NIA Y .: CetNtn Frami AIM L WA Y Door. AIM L"NIA Y 5creegFrame Aim L WA Y D DoocCasing AIM L NIA Y Founoafzon G' L NM Y 1 2.Doorjamb AM L NIA Y D Bulkhzad' AM L NIA Y 3 4 Threshold. ":L N/A Y Fences AIM L WA Y ftdoar Sill A/M L N/A Y Shutters AAA L WA Y D,' Win Casino AN L N/A Y New--I post AIM L N/A Y Window Szsh A/M:L N/A Y Raing Gap A+PA L WA Y Wii d6W Sill. Attc+f L.NIA Y I' ndraJ AIA9 L NIA Y D win. . +r?9 AI3vt L.WA IA Y 0 Muster,- AAA L WA Y # Window Sash AIM L WA Y LotrcrRail AIM L WA Y VindowSiH AJM L":WA Y Treads AIM L N/A Y D Win Casing A/M L:N/A Y Risers" AM L NIA Y WiridowSasts AhA L N/A Y Stringer jAJM L NIA Y D Lame POsi L NIA Y La Ai:1'L WA Y COi44MENTS I STRUCTURAL DEFECTS: t?rirt Pipes' L NIA Y D Elae Conduit ©, L WA Y (A7r>li Pip Z L N/A Y , Orarhang Trtrr AN L N1A Y ! Excluded Surfaces;Surfaces listed in this box can be made Soil Test Results intact only by a licensed deleader (Must be less than 404 ppm'for play area/12DO ppm for bare soil) BIDE LOCATION h4EASURE:LOOSE PAINT IC IC LOCATION AREA MEASUREME?FT RESULT REMED REhtED Q WE THAN 1440 SO,-IN.) DATE Me"TN (Square Feet) {PPR DATE METH i D D" Ply Area i Fare Soil D Cornmenti D L14 A"RepEatD,Gil a i CHECK REQUEST FANNIE MAE Date: 9.27.20V Person requesting check;. Tina Ellis Payable to: Send to:-(if different] E Township of Barnstable Regulatory Services Dept Public Health Div 200 Main.St, Hyannis, MA 02601 A.mount: $90.00 GL Account:, Loan# RE0 lD:... Property Address: Parcel#/Acco:unt#/B'lock&Lot# 5 Massa's PLj Hyannis;MA 02601 oer�messor onlV parcel id 292-316 3 i Reason°for check:; , To be'paid w/ap.plication for rental-registration,copV.attached t Special instructions for delivery .Please let Tina;:know.when ready; Tina will.mail.with completed 1 application, Thank you 1;SX f� Requestor's.Sioature: > Manager's Signature::.N/a for this�type of request. . Susan Murtagh: 571 0 0 OVERNIGHT 0 2ND DAYAIR ❑PRIORITY MAIL 0 REGULAR MAIL ❑.OTHER Date:! Ko TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: &rr)e N TiLE BUSINESS LOCATION: 5-A445Af .Rl_i,/fC& lJ/ IQAIA11S x4A ®Wl INVENTORY � MAILING ADDRESS: 5 TOTAL AMOUNT:°'° TELEPHONE NUMBER: �X3& 3 s CONTACT PERSON: QA/06 ICI�Pi1VC( ca EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? w TYPE OF BUSINESS: dct INsr�G�710 INFORMATION ./ RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. 0-V19X-fe,� 1�SiOM Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid ���Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) b Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) pp� Spot removers &cleaning fluids �W (dry cleaners) Other cleaning solvents Bug and tar removers t Windshield wash AA,,, WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials _ YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St,, Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: /G') - Fill in please: ! APPLICANT'S YOUR NAME/S: �2� ,�, -�'✓ , � W BUSINESS YOUR HOME ADDRESS: . g TELEPHONE # Home Telephone Number .50 ,56 10 NAME OF CORPORATION: NAME OF.NEW BUSINESS Al A/ ZF .STO'vr TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES . NO 2 ADDRESS OF BUSINESS L - 6 5 M MAP/PARCEL NUMBER 3� (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMWSSIO ER'S OFFICE This individu I ha a of n per it requirements that p �r,�t � t�i 96ME 0C0U.PC WRYM�ti hi - ut or d Signat RULES AND REGULATIONS. FA(LURE T© MMENT COMPI Y MAY RESULT IN FIN � T iL S� (� 2. BOARD OF H LTH This individual has be A informed of the permit requirements that pertain to this type of business. "kz wk6jj_sax- ,_� ` u hori ed SigAn�tur ** MUST COMPLY WITH ALL COMMENTS: E A-✓ /'�V� 5:�'/✓Y1� �i Le HAZARDOUS MATERIALS REGULATIONS 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Nazar ous Materials inventory Sheet GhecKllst ✓ Date Physical Street Address-Check database to ensure it exists —�—Working Phone Number 4' Actual Amounts - ( ie. gas being used to fuel machines,thinner to clean brushes all count as hazardous materials,,--no blanks) 45torage Information -location of storage, how long is storage for? if none, note that. (//1,�'' _Disposal Information -where and who? If none, note that. ----=Applicant Signature - understand what is listed and noted ✓ Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and —�—explain it ✓ Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place — Property Address Alvacir& Elizangela Marcondes -- Owner Owner's Name information is Hyannis MA 02601 March 15, 2011 required for y — 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: IIIJJJ!!!lV only the tab key to move your Patrick M. O'Connell — cursor-do not Name of Inspector use the return key. Septic Inspection Services Co Company Name 189 Cammett Road — Company Address Marstons Mills MA 02648 reran Cityrrown State Zip Code 508.428.1779 S1 12855 Telephone Number License Number B. Certification I certify that I have personally.inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by t Local Approving Authority March 15, 2011 Job# 11-31 Inspecto s Si nature 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. 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Oispo I System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Masa's Place Property Address Alvacir& Elizangela Marcondes Owner Owner's Name information is required for Hyannis MA 02601 March 15, 2011 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: Tank is not in need of pumping at this time leaching chambers had no standing water. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place Property Address Alvacir&Elizangela Marcondes _ Owner Owner's Name information is required for y H annis MA 02601 March 15, 2011 - every page. Cityfrown 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 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Masa's Place — Property Address Alvacir& Elizangela Marcondes — Owner Owner's Name information is Hyannis MA 02601 March 15, 2011 required for — every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow t5ins•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 "l 5 Masa's Place _ Property Address Alvacir& Elizangela Marcondes Owner Owner's Name information is Hyannis MA 02601 March 15, 2011 required for y — every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analyses and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa s Place _ Property Address Alvacir& Elizangela Marcondes _ Owner Owner's Name information is required for Hyannis MA 02601 March 15, 2011 - every page. Citylrown 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? ® r i❑ Was the site inspected for signs of break out? to ❑ 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 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place _ Property Address Alvacir& Elizangela Marcondes — Owner Owner's Name information.is H annis MA 02601 March 15, 2011 required for y — every page. Cityrrown State . Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: — 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No One Last date of occupancy: Date year ago.— Commercial/Industrial Flow Conditions: Type of Establishment: — Design flow (based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Masa's Place _ Property Address Alvacir& Elizangela Marcondes Owner Owner's Name information is Hyannis MA 02601 March 15, 2011 required for y — every page. Cftyrrown 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: Unknown 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): l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place _ Property Address Alvacir&Elizangela Marcondes _ Owner Owner's Name information is required for y H annis MA 02601 March 15, 2011 - every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 — feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 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: 8.5' long x 5.2'wide- 1000 gal. — Sludge depth: 2" — 15ins•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 "- 5 Masa's Place Property Address P Alvacir& Elizangela Marcondes _ Owner Owner's Name information is Hyannis MA 02601 March 15, 2011 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 baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" _ 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.): Liquid level was found at bottom of outlet invert and tees were intact. Tank in need of pumping at this time. Recommend pumping tank every three years to properly maintain system. 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 15ins•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 r 5 Masa's Place _ Property Address Alvacir& Elizangela Marcondes Owner Owner's Name information is required for y H annis MA 02601 March 15, 2011 - every page. Citylrown 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Masa's Place _ Property Address Alvacir& Elizangela Marcondes _ Owner Owner's Name information is Hyannis MA 02601 March 15, 2011 required for H y — every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 01. 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.): No solids or high stains present. — 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: 115ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Masa's Place _ Property Address Alvacir& Elizangela Marcondes _ Owner Owner's Name information is Hyannis MA 02601 March 15, 2011 required for y — every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: — ® leaching chambers number: Two 500 gal drywells. _ ❑ leaching galleries 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.): Leaching chambes had no standing water or evidence of surcharge. 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 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place Property Address Alvacir& Elizangela Marcondes Owner Owner's Name information is required for Hyannis MA 02601 March 15, 2011 _every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: — Dimensions — Depth of solids — Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Masa's Place Property Address Alvacir& Elizangela Marcondes _ Owner Owner's Name information is required for Hyannis MA 02601 March 15, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately . . . . . . . . . . . . . . . . . . . 23 3 1 34 ater Service Masa-s Place Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Masa's Place Property Address Alvacir& Elizangela Marcondes Owner Owner's Name information is required for Hyannis MA 02601 March 15, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells _ Estimated depth to high ground water: 15+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 25 and topo map shows property at el. 50. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 cf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place Property Address Alvacir& Elizangels Marcondes Owner Owner's Name information is required for �H annis MA 02601 March 15, 2011 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 J a Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. may Inspection forms not be altered in an p Y Y way. Important:When filling out A. General Information forms on the only compthe tab key r, use 1. Inspector: to move your David D. Coughanowr cursor-do not ,Name of Inspector use the return key. Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 Pending 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 inpectiog-:�fhe inspection was performed based on my training and experience in the proper function and maintena ce olEgn site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: N ® Passes ❑ Conditionally Passes ❑ isails X i 3:" ❑ Needs Further Evaluation by the Local Approving Authority a .. C (� J c.n r-- `�yr�� Ctiyr�iV•�— IL� n) rn June 18, 2007 Inspector'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. t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> Aseptic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2640.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) 3_ 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. t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 1 00.feet but 50 feet or more from a private water supply well". Method used to determine distance: ** I 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 ❑ ® 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 m 9 9 q pp , 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- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 5 Masa s Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 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? SAS also inspected ® ❑ 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)] a t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n1a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 1 Does residence have a garbage grinder? Removal of grinder is recommended ® 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 years usage (gpd)): 136 gpd Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age unknown -no records on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): 1 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: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle 28 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Probe to top of tank t5-2640.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 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.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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.): 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): t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At 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.): D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ = Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the leaching gallery. t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): t5-2640.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. LOCATIONS A B 1 23 f t 34 FL 2 14 fE 50 fE 3 23 fE 74 f t EXISTING DWELLING # 5 A 8 LEACHING GALLERY w 0 0 2 ? J ❑ O O O-60X SEPTIC I 3 TANK M A S A' S PLACE NOT TO SCALE t5-2640.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's Place Property Address Mary Smachetti Owner Owner's Name information is required for Hyannis MA 02601 June 18, 2007 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 20+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. t5-2640.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 ..opt"E Tati Town of Barnstable Regulatory Services sA�NSTABLE, * Thomas F. Geiler,Director MASS. 9� 16s9• .m Public Health Division AtfD��A Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Mary L. Smachetti Date: 4/29/04 5 Masas Place Hyannis, ma 02601 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 5 Masas Place, Hyannis was inspected on, 5/13/99 by Robert Bortolotti, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Backup of sewage into facility due to an overloaded SAS.. Our records show that the system has been in a failed state for more than two years. You are ordered to hire a professional engineer or registered sanitarian to prepare a plan of proposed replacement septic system component(s). This plan is to be submitted to the Town of Barnstable Public Health Division Office (Regulatory Services, 200 Main Street,Hyannis), within (90) days receipt of this letter. The plan will bring the septic system into compliance with 310 CMR 15.00,The State Environmental Code, Title V. You are also ordered to upgrade or replace the septic system within six months (180) days of your receipt of this letter. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. You have the option of requesting an adjudicatory hearing pursuant to 310 CMR 15.422 Failure to comply with this order will automatically result in a public hearing scheduled before the Board of Health. PER O F BOARD OF HEALTH s .McKean,R.S., C.H.O. Agent of the Board of Health CC: Board of Health JAaded_septic_lettets r Septic Inspection Information ::::<.P;, 292 <> €?ata.; 316 .. Elie 5 .....> IMasas Place 14 Hyannis €<€lis# sr€ Robert Bortoiotti IF ........................ ........................ ........................ s Bckup of sewage into facility due to an overloaded SAS, ........................ 993901 ii:.iSi � :7�'�7Ri"�.,a,{ iiiibi�•f2ti7FQbfY BORTOLOTTI CONSTRUCTION, INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date of Inspection: 5S/4o/99 hnspector's Name: Own is Name and 4lddress: ' Mile ION STATEMENT!* I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is.true,accurate and complete as of the time of inspection.,The inspection was per- formed based on m training g and d experience in the proper function and maintenance of on-site sewage' disposal systems. The System: Passes . Conditionally Passes Needs Further E lion a Local Aproving Authority Fails _ Inspector's Signature: ignature Date: 7 F The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design now of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of.the.Department of,Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARYo`, A)SYS,''E PASSESs I have not found any information which indicates that the system violates.any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated .below. B)SYSTEM CONDITIONALLY,PASSES; One or more system.components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or ;.exfiltradon,or tank failure is imminent. The system will pass inspection if the.existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water,level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): SUBS URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A i CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstniction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if. the system is failing to protect the public health,safety and the environment. 1),SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE' SYSTEM.rIS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE " PUBLICZEALTH AND SAFETY AND THE ENVIRONMENT: 1 or n is within 50 Feet of a surface water Cesspool privy ,... Cesspool or privy is within 50 Feet.of a bordering vegetated wetland or a salt marsh. Z)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH,,(AND'PUBLIC WATER ' SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM,IS.FUNCTION- ING IN A MANNER THATTROTECT THE PUBLIC;HEALW AND SAFETY°AND THE'. ENVIRONMENT. The system has aseptic tank and soil absorption system and is within 100 Feet to a surface w °water supply or tributary to a surface water supply.' " The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. 'x The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from, the-facility.and the-presence�of ammonia nitrogen and nitrate nitrogen is equal to or less' : than 5 ppm:' D)S STEM:FAQ.S:' V I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health sho d be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding-of efluent 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'inveit-due to an overloaded.or clog ged SA&or cesspool IJ Liquid depth in cesspool is less than 6"below invert oc available volume.is less than,l/2 ,day now. .+r _ .... Required pumping more than 4 times in the lasuyearl=d"ue to clogged or obstructed 4 7 pipe(s) Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a'system is•10,000 gpd ougreater(Large.System)and the system is a significant " threat to'public health and safety and the'environmeut because-one or more of the following. conditions-exist: .. u. . , •y., , i } The system is'withi&460 Fee[of a surface drinking'wateusupply.. ' •. ,'. The system is within 200 Feet of a tributary to a surface drinking.water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of,any,such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ,Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks and the system has , been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓�-built plans have been obtained and examined. Note if they are not available with N/A. JGThe facility or dwelling was inspected for signs of sewage back-up.• —,,:ffhe system does not receive non-sanitary or industrial waste flow. r s;[' t/1`heaite:.was inspected:fousigns of breakout. _tAll,system components,excluding the Soil Absorption System,,have been located on site. ,�r' e;septic tank manholes were uncovered;.opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, th of sludge,depth of scum._ he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. 3- 4 c 'ti "F SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART B CHECKLIST(continued) The facilityowner(and occupants,if different from m owner)were provided with information on the proper maintenance of Subsurface.Disposal System SUBSURFACE;SEWAGE DISPOSAL.SYSTEM(INSPECTION,FORM.-,s ' PART C SYSTEM INFORMATION FLOW CONDITIONS RE'gMR Y.TIAL: DesignFlow:-.3W gallons Number of Bedrooms: v2 Num r of Current Residents: Garbage Grinder: Laundry Connected To System:< Seasonal Use: Watq.,Meter Readings,ifavailable: Last Date of Occupancy ' . s. r .,s. i .. J ... ..a L.A .. .. t. ,a1..• ""COMMEAC110JINIb Type of Establishment: Desi��' ,i±allons/day Grease Trap Present: (yes or no) gn.Flow � 'r Industrial Waste Holding Tank Present Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPINGRECORIDS and source'of information: Of., System Pumped as part of inspection: A){� If yes,volume pumped: gallons Reason for pumping: TYP SYSTEM:, tic TapVDistribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection'records,if Other(explain): __. . ._. PROXIMATE AGE,of all comments.date installed(if known)and source'of inforniaUon = ` -" ` ge-odors.detected n arriving at the site: AX ' -4- SUBSURFACE SEWAGE.DISPOSAL SYSTEWINSPECTION FORM PART C . .. GENERAL INFORMATION (continued) SEPTIC TANK: V Depth below grade: Material of Constn►ction: V Concrete metal FRP Other (explain) - DimisIons:S1.5'X to ' X -1 Sludge Depth: '-' Scum Thickness: " Distance from top of sludge to bottom of outlet tee or baffle: jr5- Distance-from bottom of scuiri'f6bottom of outlet`tee or baffle: - j; Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation t utiet invert,structural integrityevidence of leakage. GREASE TRAP: d Depth Below Grade: Material of Constn►ction: concrete metal FRP Other (explain) — — — — Dimensions: Scum Thickness: - Distance from top of scum to top of outlet tee or baffle: ' Comments: (recommendation for pumping,condition of inlet and.outl`et:tees or'baBles depth of li4did- level in relation to outlet,invert,_struc(ural integrity,evidence.of.leakage...etc.,),-._ TIGHT OR HOLDING TANK: Depth Below Grade: Material of Constn►ction:__concrete—metal—FRP—Otl►er(explain) Dimensions: Capacitv: gallons Design Flo%v: gallons/day Alarm Level: Comments:-(condition of inlet tee, condition of alann and float swi(ches, etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if kevelapd distribution is equ I,evi nce of solids carryover,evidence of leakage into 0 out of box,etc.) Y :PUMP CHAMBER:_.. . .. Pump is to worku►g order .: f , <`, � a �^�- � _ . . .- • °a, `, - Comments (note condition of pump chamber condition of pumps and-appi►rtenances,etc) Wu 4 ,:;,,�, �„,y; 1��yi,.21,Y•E•+'7A'.�"3€,fir t,�+s�;,;d�y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL.ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: ,* Leaching pits,number: / Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: gC40 tsi(note condition of soil,sit ns of hydraulic failure level f ponding, ondition of vegetation, CESSPOOLS:V O w s 3 r 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(cesspool must be pumped as part of inspection)_ Comments: (note condition of soilk, signs of hydraulic failure, level,of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) -6. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. �f ✓✓ �3 i DEPTH TO GROUNDWATER: Depth to groundwater: H Feet �J Method of Determination or ppr ximation: Apm , COMMONWEALTH OF MASSACHUSETTS TQ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 1 D TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ` a CERTIFICATIONq. Property Address: 5 Masa' a Place - < -s i Hyannis ry Owner's Name: Mary Smachetti cis ; Owner's Address: _ v' Date of Inspection:_ a-1"a CD cap M Name of Inspector:(please print) Wi 1 1 i am _ •Robi nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT i certify that 1 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.1 am a DEP approved system inspector pursuant to S tion 15340 orTitle 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: —C�t 4 c The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthvr 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 approxing authority. Notes and Comments ****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 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION(continued) Property Address• 5 Masa s Place Hyannis Owner. Mary STacheEti Date of Inspections Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst 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: B. System Conditionally Passes: One or more syst m components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upo completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not det rmined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is r ietal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits subs ial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the - existing tank is replaced ith 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 i less than 20 year old is available. ND explain: Observation o sewage backup or break out or high static water level in the distribution box due to-broken or _ obstructed pipes)or ue to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board o Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced M explain: The system quired pumping more than 4 times a year due to broken or obstswcd pipe(s).The system will pass inspection if(WI approval of the Board of Health): broken pipe(s)are replaced Obstruction is rsmovcd ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5 Masa' s Place _ Hyannis Owner: Mary Smachetti Date of Inspection: . C. Further Evalua t n 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 publ c health,safety or the environment. 1. System will pas unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not fu ctioning in a manner which will protect public health,safety.and the environment: _ Cesspool o privy is within 50 feet of a surface water — Cesspool o privy is within 50 feet of a bordering vegetated wetland or,a salt marsh 2. System will f it unless the Board of Health(and Public Water Supplier,if any)determines that the system is functi ing in a manner that protects the public health,safety and environment: _ The sy tem has a septic tank and soil absorption system(SAS)and the SAS is within.100 feet of a surface wa Cr supply or tributary to a surface water supply. _ Tb System has a septic tank and SAS and the SAS is within a Zone I of a public water supply. — Th' system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The stem has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frohl a private wa r supply well•• Method used to determine distance "This syst in 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5 Masa is Place Hyannis Owner: Mary Smaehetti Date of Inspection: D. Syst m Failure Criteria applicable to all systems: You must indicate'yes".or"no"to each of the following for all inspections: Yes No ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool D'scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or cl gged'SAS or cesspool S tic liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cc pool Liq id depth in cesspool is less than 6"below invert or available volume is less than day flow Req fired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of ti es pumped _ Any onion of the SAS,cesspool or privy is below high ground water elevation. Any -ortion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface wate supply. Any dortion of a cesspool or privy is within a Zone I of a public well. .Any PCrtion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet Gom a private eater suppl well with no acceptable water quality analysis.(This system passes if the well water analysis, pert rmed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indi fates that the well is free from pollution from that facility and (lie presence of ammonia nitr gen 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.l (Yes o)The system fails.1 have determined that one or more of the above failure criteria exist as d scribed in 310 CMR 15.303,therefore the system fails.The system owner should contact the Boar)of ealth to determine what will be necessary to correct the failure. E: Larg Systems:To be co sidered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You ust indicate either"yes"or"no"to each of the following: (11e f owing criteria apply to large systems in addition to die criteria above) yes no e system is within 400 feet of a surface drinking water supply th system is within 200 feet of a tributary to a surface drinking water supply Jsystem is located in a nitrogen sensitive area(interim We Protection Area—IWPA)or a mapped Zo a 11 of a public water supply well , If you have swered"yes"to any question in Section E ttte system is considered a significant threat,ar answered "yes"in Se ton D above the large system has faikd.The KmmeT,oroperator of fury large system considered a significant teat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. _j t m owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 5 Masa' s Place Hyannis Owner• Mary Sm chetti Date of Inspection: -° G Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes NVpul _ ping information was provided by the owner,occupant,or Board of Health _ ere any of the system components pumped out in the previous / two weeks Has the system received normal flows in'the previous two week period? V Have large volumes of water been introduced to the system recently or as part of this inspection T. 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 1/ — Was the site inspected for signs of break out? v 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: Yes no/ (/ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 5 Masa' s Place Hyannis , Owner: Mary Smachetti Date of inspection: - FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. 3 Number of bedrooms(actual): 3 f DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): c�0 Number of current residents: d� Does residence have a garbage der(yes or no):�a Is laundry on a separate sewage system(yes or no):4,oo [if yes separate inspection required] Laundry system inspected( es or no): Seasonal use:(yes or no): 0 Water meter readings,if aai ble(last 2 years usage(gpd)): 2 0 0 4 — 3 5, 2 5 0 Sump pump(yes or no):_vv 2003 — 44, 250 Last date of occupancy: COMMERCIAL/I STRIAL Type of establishm nt: Design flow(bas on 310 CUR 15.203): gpd Basis of design Pow(seats/persons/sgft,etc.): Grease trap pr sent(yes or no):_ Industrial wa to holding tank present(yes or no):_ Non_ sani waste discharged to the Title 5 system(yes or no):_ Water met r readings,if available: Last date f occupancy/use: OTHE (describe): GENERAL INFORMATION Pumping Records Source of information: l c c Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: GTYP 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/Altcmative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and souice of information: Gj A �j A, ►, 6U 5,0S Were sewage odors detected when arriving at the site(yes or no): /L 6 4 Pau 7 of I 1 OFFICIAL INSPECTION FOR AI-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR11I PART C SYSTEM INFORMATION(continued) Property Address: 5 Masa' s Place yannis Owner: Mary Smac e i Date of Inspection. ;Z.7-Q BUILDWER(locate on site plan) Depth ade: Materistruction:_cast iron _40 PVC_other(explain): Distanrivate water supply well or suction lute: Comm./condition of juutts,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) ) Depth below grade: 7 Material of construction:_✓onctcic metal fiberglass�,olyeth"ylene _odicr(explain) _ If tank is metal list age:r Is age confir-ned•by a Certificate of Compliance(yes or no): certificate) —(attach a copy of , Dimensions:_, 4, Lf x Sludge depth: Distance from top of sludge to bottom of outlet Ice or baffle: Scum thickness: O , Distance from top of scwn to top of outlet tee or baffle: 1 Distance horn bottom of scum to bottonn of outlet tee or baflle: I low were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or bathe condition,structwal integrity,liquid levels as related to outlet invert,evidence of leaks e,etc.): zx- GREASE TRAP:_(locate on sit plan) - Depth below grade:_ Material of construction:_con rote metal fiberglass_}rolyedlylene other (explain): — Dimensions: Scum thickness: Distance from to of scwn tot p of outlet tee or baffle: Distance front bottom of stun to bottom of outlet tee or baMe: Date of last pumping: Conunents(on pumping reco nntenda►iuns,inlet and outlet tee or baflle conditio:,structural integrity,liquid levels as related to outlet invert,ey Bence of leakage,etc.): 7 Page 8 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENVACE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR IATION(continued) Property Address: 5 Masa' s Place Hyannis Owner: Mar}� Cmarhettl Dale or laspcctlon:_ TIGIIT or HOLD G TANK: (tardc must be pumped at time of inspection)(locate on site plan) Depth below grad : Material of cons ction: concrete_metal_fiberglass_polyethylene o►her(explaut): Dimensions: Capacity: gallons Dcsign Flo gallons/day Alarm pies nt(yes or no): Alarm lev I: Alarm in working order(yes or no):_ Date of I st pumping: Comrnel is(condition of alarm and float switches,etc.): DISTiiIDUTION BOX: present must be opcncd)(locate on site plan) Depth of liquid level above outlet invert:_(� Conunents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of - leakage into or out of box,cic.): -lry e— d t PUMP CUANIBE.M (locale on site plan) Pumps in working o der(yes or no):— - Alarms in workin order(ycs or no):— Conunents(not ondition of pump chamber,cundition of pumps and appurtenances,etc.): f Page 9 of I 1 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Masa' s Place. Hyannis Owner: Mary Smachptti Date of Inspection: . SOIL ABSORPTION SYSTEM(SAS):2(locate on site plan,excavatiodnot required) If SAS not located explain why: Type 1 j�aching 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: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool st be pumped as part of inspection)(locate on site plan) Number and configuration: _ Depth—top of liquid to inle invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspoo Materials of construct' n: Indication of ground ater inflow,(yes or no): Comments(note co dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): _ PRIVY: /consction: n site plan) Materials o DimensionDepth of sCommentsion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): F' 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Masa' s Place Hyannis Owner: Mary mac e i Date of Inspection: O SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. oy-I 3 7 10 Pagel l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Masa' s Place Hyannis Owner. Mary SQachetti Date of Inspection: — �G SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water l 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 design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mpt describe how y u e tablished the hi h ground water elevation: 11 Commonwealth of Massachusetts ` dWh 'Jilly Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Masa's PIS J Property Address r„ Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is s' required for every Hyannis MA 02601 10-31-17 y page. City/Town State Zip Code Date of Inspection ,`xx 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. A. General Information 1. Inspector: ; Shawn Mcelroy Name of Inspector Upper Cape Septic Service - Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification , I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of ` Title 5 (310 CMR 16.000).The system ' ® Passes. • ❑ Conditionally Passes ❑ Fails,- ❑ Needs.Further,Evaluationby the Local Approving Authority 10-31-17 nspector's Sigriature 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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 ,lo VS AV CO.MMO.NWEALTH OF MASSACHtiSETTS EXECUTIVE OFFICE OF E:�'VIRONME\TAL AFFAIRS �• t� DEPARTMENT OF ENVIRONMENTAL'PROTECTION ONE WINTER STREET. BOSTON KA 0210E (617) 292-550o TRUDY COXE Secretan ARGEO PAUL CELLUCCI DAVID B. STR17HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 5 Masa' s Place Name of owner Virginia Leukhardt Powers Hyanni%,nMA AddressofOwnw:pn Rnx 338, H_�rann sznort , MA Date of Inspection: Name of Inspector:(Please Print)Wm. E . Robinson Sr . I am a DEP approved systerq inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) company Name: Wm. E . Robinsoneptic Service Mailing Address: PO BOX 1089, Centerville, MA Telephone Number: �7 7 —8 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!;c time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site seww a disposal systems. The system- Pass. Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Q Q Inspector's Signature: a Date: T y".•� < J The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS 0- it's 6E>��vE� r 0 1gg9 . PSG 2 ti 1,sti�ete 'Y 'IG OD�TMpE¢i; x v revised 9/2/98 Pagc•lof11 %J Pr:nred on Recycicd Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ; PART A CERTIFICATION (continued). 'rop"Address: 5 Masa' s Place , Hyannis, MA JwrW: Virginia Leukhard.t Powers Date of Inspection: �4 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: . c s One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are.replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed r.�ty revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prop"Address: 5 Masa' s Place , Hyannis ,MA Owner: Vriginia Leukhard.t Powers Date of Inspection: 1 —,;to.-� `� * v} V ry C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 1 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) c . Property Ad&ess: 5` Masa' s .Plq ee , Wyannis, MA Ow�r: ,.:- rirgina leukhardt Powers Dete of Inspection: o g ;r D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility-or system component due to'en 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipelsl. Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. ,LARGE SYSTEM FAILS: You imust indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Arjdress; 5 Masa ' s Place , Hyannis , MA Owner: Virginia Leukhard.t Powers. Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with NIA. �i _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow.. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)1 - _ The facility owner(and occupants,if different from owner) were provided with information on the propermaintenaac."f Subsurface Disposal Systems. revised 9 2 98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 4operty Address: 5' Masa' s Place Hyannis, MA owner:Virginia 'Leukhard.t Powers R Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 0 g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms (actual Total DESIGN flow Number of current residents:-.2-- Garbage grinder(yes or no):k0 Laundry(separate system) (yes or no):,j,0 If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):,6�_6 Water meter readings, if available (last two year's usage(gpd): Sump Pump(yes or no):-,�-_d Lest date of occupancy:-2--1—L6--f COMMERCIALFINDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow 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) Water meter readings,if available: Last date of occupancy: OTHE (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: l 7' System pumped as part of inspection: (yes or no),& 4 If yes, volume pumped: gallons Reason for pumping: TYPE 0� ` STEM v� 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) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known) and source of information: _ ` '•`7 Sewage odors detected when arriving at the site: (yes or no)Ar revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 5 Masa' s Place , Vannis , MA rer Owr : Virginia 'tleukhard.t °We Date of Inspection: BUIteDING SEWER: (Loc a on site plan) Depth below grade- Mate al of construction:_cast iron_40 PVC_ other(explain) Distance from private water supply well or suction line Dia Teter Co ments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) r J ' Depth below grade: D Material of construction: ✓concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age /_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: z `✓ Sludge depth: t0 Distance from top of sludge to bottom of outlet tee or.baffle: (� Scum thickness: (3 — t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom o tlet tee baffle*J j� How dimensions were determined: A r� lomments: (recommendation for pumping, condition of inlet and 9 utlet ror baffles, depth Off.liquidtlevel in relay''an to outlet invert, structural integrity, evidence of leakage, etc.) Z06 0�/ /� �" �� fi/e GR SE TRAP: (local on site plan) Depth b low grade:_ Material 9 f construction:_concrete_metal_Fiberglass ._Polyethylene_other(explain) Dimensions: Scum th ckness: Distanc from top of scum to top of outlet tee or baffle: DistancA from bottom of scum to bottom of outlet tee or baffle: Date o last pumping: Co ants: (r commendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, ev ence of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) +ropertyAddress: 5. Masa' s Place , hHyannis, MA owner: Virginia:. ' Leukhard.t Powers Date of Inspection: /— TI T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (loc e on site plan) t Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capaci y: gallons Design flow: gallons/day Alarm resent Alarm level: Alarm in working order: Yes_ No_ Date o previous pumping: Corn nts: (condi ion of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: L (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - 1�C� PUMP CHAMBER:_ (locatef on site plan) 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.) revised 9/2/98 Page 8orll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 5 Masa' s Place , Hvannis , MA Owner: Virginia Leukhard.t Powers '. Date of Inspection: d `j SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Altemative system: Name of Technology: Comments: (note condition of soil, signs o)draulic failure, level of ponding, damp soil, condition of vegetation, etc.) Xesy ` CESSPOOLS:_ (locate on site plan) / Number and configuration: eM Depth-top of liquid to inlet inv Depth of solids layer: A A )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note,condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 1 PRIVY:_ (locati on site plan) r Materials of construction: Dimensions: Dept of solids: C ments: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Addre : 5 Masa'x s Place , Hyannis , MA Jwner: Virginia Leukhard.t Powers Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public.water supply comes into house) f!Z Oq •� rs- revised 9/2/98 Page 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) roomy Address: 5 Masa ' s'-' Place , Weiss, MA Ownw: Vir- ginia Lbukhard.t Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater i�'�Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc:) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 z o BARNSTABLE SEWAGE VIIfi,A�E Gt h 4 ASSESS0IZ'S.M�41?�i I.ax IN5TI .LBLt'5 NAhM&PHONE NO E c TAPI'K COACIT 1 O . �. .Y.- (size} NO p 11rDItOOMS 1RNdIT fAA' ....�. Gt�P/td"U�/�T+IfE AJ�T ... 8eprazaeiott lf9tseust�a Between tl�e ex mum" ►}listed G► AII)dwatet Tableto tlacBattom ofLoai�hln l�f�c+licy 1�1va94 yVp& r Supply w. 41 f�i ea l�c�g 1'ac�laty GfSe�ty�»tls cx4st R0i aft eita ae.:within aQp felt of lenctuotg Cttcibty) Ectui cyfle4au1 and Leactin� ncil(ty(Y�uny wetlands exile fee tvithu1300 fee of 1caCiiing tuclt ) 0 W v � � r ct w W WTJ a a � W 1 ^ 1 r f . TOWN OF BARNSTABLE 'LOCATION (���c.°S yt S # - �gP VILLAGE ASSESSOR'S MAP&PARCEL q S NAME&PHONE NO: SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (��i lie.M it)t rs (size) �00 NO.OF BEDROOMS OWNER a S PERMIT DATE: C DATE �,,P- (IS 11 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility, Feet FURNISHED BY C ��M 0 \ Y \ Y L h \ \ \ \ \ \ Y Y ♦ L h \ 4 \ h \ L + \ \ Y Y ♦ Y L L-Y \ \-L Y h Y \ Y L Y \ Y L ♦ �� \ L \ \ ♦ L h L Y L L L h \ \ \ \ Y - \ e. L L t L \ Y L L t-:t \ Y \ ♦ Y Y \ ♦ L - l L ♦ \ Y Y \ h L h \ Y 4 °v Y Y Y L \ L \ \ L L \ . L L L L Y ♦ k Y ♦ L.♦ L L Y L +. t L L \ Y \ Y f f f f f f / f f f J / / J f / / \ Y \ L L \ \ ♦ ♦ \ \ ♦ \ I. ♦ h Y Y ♦ L L L ♦ L L L h \ \ L L h h f / f / / J i / / h Y \ Y \ \ \ \ \ ♦ ♦ \ L \ ♦ .. 23 3 1 34 ater Service Masa's Place TOWN OF BARNSTABLE iL�OCAT10I1 M�S�!.5.,sLACL� SEWAGE # V11LAGE` H Y 9r ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any'wetlands exist within 300 feet of leaching facility) Feet Furnished by fit®- 10 LOCATIONS A B EXISTING 1 23 Ft 34 Ft DWELLING 2 14 Ft 50 Ft # 5 3 23 Ft 74 Ft A B LEACHING GALLERY w ° 0 2 ? J ❑ O O I -BOX W H SEPTIC I 3 TANK M A S S PLACE NOT TO SCALE JeOCATIOM SEWAGE PERMIT NO. KILLAGE i. I N S Tf LLER'S NAME i ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED -2y DATE COMPLIANCE ISSUED �-2 ��— W 7 1 � a. YU00"(7 M . Fss............... ......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH IT h .-..-....--.o F.- / ... 1- - �7l ,�-------------- Appliration for Diopooal Vjarkfi Tonotrur#ion famit Application is hereby made for a Permit to Construct (k/) or Repair ( } an Individual Sewage Disposal System at: r .......W­ g .. � �: ........---...._.....__•-••••-•.•-•--•_-_.... ..................................... .._____..__........ ....- Location-A re w or Lot ........... ...__•____._..A.......... _____•-- •-•••••••••-•.....__.... ...__•_ •__........_.....................___ner � �� ._ �a._.Installer AddTyp .Size ot._l043EiR......Sq. feet U Dwelling—No. of Bedrooms............ ___________________Expansion Attic ( ) Garbage Grinder (A/&) Other—T e of Building ........... No. of persons____________________________ Showers — Cafeteria dOther fixtures ........................................ W Design Flow_____________/IV.�.........................gallons pe � lergday. Total doily f�ow..............3 ._ f.__._.__.___ Ions. WSeptic Tank—Liquid capacitylt9a)_.gallons Length_9_:`_(r�_ ___ Width_4_9j0 Diameter________________ Depth 0____- x Disposal Trench—No_____________________ Width___t.___{i_.__.___._ Total Length Total Total leaching area....................sq. ft. Seepage Pit No.......I............ Diameter....W.D.... Depth below inlet___`T1_._._. Total leaching area...2Z_7...sq. ft. Z Other Distribution box (k-r Dosin tank1­4 ) Percolation Test Results Performed b _ ' _ E/1 � r � ._ Date..........�1 z .._....__. a y- o {dj ,4 Test Pit No. 1 lfl:_�2_-__minutes per inch Depth of Test Pit...1'2_:_G�...___. Depth to ground water____d��_erle Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to r r........................ R+' o ... ............... � H OF M9ss• - -•-•-------------- O Description of_Soy____- t°_ /fir?..E__ r.�.��P---dam f!!®t?? -�� Pd ----_-_---. -�,'_....itANa.....qc v .��bsO.tl�.. '. -• �'�!_,�1�`ll ... ?". j'._. - '� �r��i�bao Si?d ..........W,..........�- ---------------- Wl ' c.S__51f���/�d ---------- -0 BOcK1:�1�NIE v, UNature of Repairs or Alterations—Answer when applicable....................__________ ________ __�- No:14704 p -----------•-----------------------------------------------------------------------------------••----•---•-------•-•-. F Agreement: ON The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sy accordance with the provisions of LITNE 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance 1 n is by t oard of health. Stgne _--• -- •• ............................. -------------------------------- t Dam Application Approved By---••""r..." = �:.. . - ---- ..................... ...9_`2•l-- - Date Application Disapproved for the following reasons:----------•--------------------------------------------------------------------------------------------------•-• --------------------------------------------•--------------------------------------..........----.._.......------------------------------------------------------------------------------------------_--- Date PermitNo......................................................... Issued_--- --- .......................... Date No........................ .'' Fim......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................/V' )............OF.... -Z. 4f�7L�.....t..17 t!?I�1............__ Appliration for Uigpooa1 Works Tomitrurtion Prrutit Application is hereby made for a Permit to Construct (k,,) or Repair ( ) an Individual Sewage Disposal System at: _ .....__�� .`�c .ia... � �......... --D .. .......... -• ............. - ........_...................._ s Location-Address or Loto -• .................. ....... ..L-4.......... .................................Z:7�._d Owner V fj Address J ................ ......_... ...... .......... ..... - ._ .. .......... Installer `" AddressC Type-of�Building Size ,L,ot...10,L. 3rg.....Sq. feet U Dwelling—No. of Bedrooms............., _ ......................Expansion Attic ( ) Garbage Grinder (ND) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures """""""""""".-------------------•---•-------•---___-----------------,::-_-..........._•----_----•--•-••..._.. W Design Flow............../e49..............._..__..gallons per p6sen er day. Total daily flow.__............3, ...............Olons. WSeptic Tank—Liquid capacity.l�,�YLgallons Length .".?..... Width.A.._1 Diameter................ Depth__.__': .._. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........I............ Diameter.._.-t .. -_-- Depth below inlet.._ Total leaching area...6.7..sq. ft. Other Distribution box (k� Dosin tank ) z '-' Percolation Test Results Performed ..... Date...._----_//- 2/1 zS_.__..__. a "' Test Pit No. 10PJer.Z.minutes per inch Depth,of Test Pit.. Depth to ground water./V!){',C_._.e.12C, Test Pit No. 2................minutes per inch Depth of Test.Pit.................... Depth to dy _._______-___._______- O ! _._._-••--_`_-•........................... •-----.............................-•-•-�•-•-••-•-••• �y� . ..........q.1P. .................. . _Description of So�lf....:7a°�._ ?..�t �-.�.+ - �•-•ls� � :?r.'� -1....-•--•_•--•_-. . ......DANA........ ............... W. S_ _s /?�c r�1!rl S� •%'!�'' �---_j-----• ....--McKECHNIE •----------- � � � No.f�7U4"'�"�" V Nature of Repairs or Alterations—Answer when applicable................................. moo. .E....._.. .. ._._...._...... � . Agreement: N The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with . the provisions of iIT..:L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in V operation until a Certificate of Compliance has..been issued by theAoard of health. , -_ Signed -- l v. ./ Date Application Approved BY----. lee .. _ '?----------------•--- ! '"', °"_ ` • !,: r Date -pp lication Disapproved for the following reasons:-------•----•..................••--••-•--------••••_••_•----•--••__------------•-------- --•-------•-----..« Date PermitNo------------ ...........................................' Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... Tertifira f Toutpfianre TI IfIS,IS T CER T FY,:That the In u sewage Disposal System constructed (4" or Repaired ( ) . . .� by �r✓�1 f Inst i .. - .... { PIJ,�s i -S. •_,•Y j( <q- -- -............t--,---� ' �` '��:e► .......-__-••....._ has been installed in accordance with the provisions of j The State Sanitary Code as described in the ,• ,+ application for Disposal.Works Construction Permit No �_:. ___ 7-_____.____ da.ted._. �* ._... '_.°__..___.___. THE ISSUANCE,OF THIS CERTIFICATE SMALL.NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....... ....._-----••--•--•--......•--_. Inspector = ... .. :....... THE COMMONWEALTH OF_MASSA�CHUSETTS BOARD OF HEALTH r ........OF..... .•r ............................................ FEE...., •: No.................... .... y M.5p at. or ,v .onotrud .,utit Permission 's h reby gran.Eed:.. - --.. - ........ .'to Construe ( ortRep ( an Indiw§'dual e ;age Disposal System r / yy ,�; at No.- } ••. :*�...../ tE% `ff w.. ._ s, b.... e ,. . Q!`w�E ,,._ _- • -- •- as shown on the application for Disposal Works Construction, P rmit I Date . ,*+_ �.�m ' ! � f/ DATE. .. ... ... �� FORM 1255, HOBBS & WARREN, INC., PUBLISHERS i'Box r`t, _t. Ilk RUN. 4,F4,+ AFRECAS E R TU Ifr,�-4 zt�u vMINIM �,40,U N DA TU IWASHEDXST�N I'tin PER_�T E KE TC N E-VE V At,,`UO W_,A�, 0 N',d t4i SQ Ppf"I W "OEROPERATOR,',�WA EtT DE,.-I ?'7 I 'k Top q�tl tr N IIIIITim t iIn .7-L I :�r if fIle, 45�7,IIIkk -t II1t 79$;O:� y IILj c-r4w -SE;p4 PRO FO F L N D AT-oo:N 9-I N W, �Fbr I �v i�0' SEPTIC TANX!t" IT_`0 F'!�!S't P'Y 1*IP4'M A-1-0 N 9 vr. W.-c�O N-S�U LT­"C 0 D�r, S U K VE,y�,�,._[vu I 4 (-5&�T AN'TS,,� T V Y4COWSULTAMT. III