HomeMy WebLinkAbout0772 OLD STRAWBERRY HILL ROAD - Health 172 Old Strwberry, Hill Road ;
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Town of Barnstable
Regulatory Services Department
Public Health Division
200 Main Street,Hyannis MA 02601
Office: 508-8644644 Richard Scali,Director
Fax: 508-790-6304 Thomas A.McKean,Agent
Certified Mail#7008-3230-0002-5177-7851 February 24,2015
Mr.James Williams and Ms.Lori Williams
765 Old Strawberry Hill Road
Centerville, MA 02632
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000.STATE SANITARY
CODE H-M04LVIUM STANDARDS OF FITNESS FOR HUMAN HABITATION
The property owned by you located at 772 Old Strawberry Hill Road,Hyannis;Map/Parcel
274-015,with a mailing address of 765 Old Strawberry Hill Road,Centerville„was
inspected Saturday February 21,2015 at 8:12 p.m.by Thomas McKean,Health Agent for
the Town of Barnstable. This inspection was conducted on the basis of a complaint
received at the Police Department. The following violations of the State Sanitary Code
were observed:
105 CMR 410.602(B): Build-up of foreign debris and feces on the floors of the dining
room,living room,kitchen,and hallway. Piles of plastic containers, food items, ,
wrappers and other debris on top of the kitchen counters.Piles of debris observed on the
dining room table and on the living room floor adjacent to the children's play pen and
children's swing. Spider webs and spiders observed at the living room ceiling.
105 CMR 410.450: Means of Egress: Waste baskets and other items blocking rear
kitchen door- secondary means of egress.
105 CMR 410.482: No smoke detectors provided.Also,no carbon monoxide detector
provided. [NOTE: Smoke detectors provided later than night, supplied by Hyannis Fire
Department].
105 CMR 410.500: Broken and missing ceiling tiles exposing insulation and boards
located in the front answering service work room.
You are directed to correct the violations of 410.450 and 410.482 within twenty four
(24)hours of your receipt of this notice by removing the waste baskets and other items
blocking the rear kitchen door and by maintaining operational smoke detectors and
carbon monoxide detectors inside this dwelling.
You are ordered to correct the violations of 410.602 (B)within ten(10)days of your
receipt of this notice by removing the feces and ground-in foreign debris from.the
QAOrder letters\Housing-Motel Violations\772-aka765 Old Strawberry Hill Rd Hy-Cent.Williams.doc
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floors,walls, and ceilings throughout the dwelling; by removing the piles of debris
from the kitchen counter-tops, living-room, and dining room; and by clearing the
spiders and spider webs from the living-room ceiling.
You are also ordered to correct the violation of 410.500 within thirty (30) days of
your receipt of this notice by repairing the ceiling in the front answering service
work room.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten(10) days after the date the order is served.
Non-compliance will result in a fine of$100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations,please contact me at(508)
862-4640.
=McKean,
D OF HEALTH
Director of Public Health
Town of Barnstable
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'` Centerville, MA 02632
Certified Mail Provides: !
a A mailing receipt .
o A unique identifier for your mailpiece
a A record of delivery kept by the Postal Service for two years
Important Reminders:
o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®.
n Certified Mail is not available for any class of international mail.
a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
n For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
e For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
n If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post-office for°postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
PS Form 3600,August 2006(Reverse)PSN 7530-02.000-9047 1 14 .
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Commonwealth of Massachusetts �' Ot
Title 5 Official Inspection Form
Subsurface Sewage Disposal System)Form-Not for Voluntary Assessments
�Id Hill Rd. Ge itewiNe, ACOV2632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owner's Name
infbmiatiOn is -o
fe9uoW for every Osterville MA 02655 W812016
pap Cilylrown state Zip Code Data of inspection
m
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please we completeness checklist at the end of the form.
fi,' out A. General Information
on the comp tr
use only the tab 1. Inspector
key to move your
cursor-do not Paul Martin
use the return Name of Iron
Cape Cod Septic Services
Cry Name
VQ 350 Main St
Cornpany Address
,�. W.Yarmouth MA 02673
Cityrrown State Zip Code
508-775-2825 S15016
Telephone Number Lkxmse Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems.I am a DEP approved system inspector pursuant to-Section 15.340-.of
'title 5(310 CMR 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/5/2016
1410mWs 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 DER 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 dMerent.conditions of use.
t5hiS,W13 rft 5 Offiow! Form stossfam Sewrape Dmpwd System•Pape 1 d 17
NO V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
765 OId Strawberry Hill Rd Centerville, MA 02632
Property Address
Ann Williams 39 Blossom Ave. #6
Owner Owner's Name
information is required for every Osterville MA 02655 9/28/2016
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 in working condition.
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 exMtration 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.,3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
765 Old Strawberry Hill Rd Centerville MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owners Name
information is Osterville MA 02655 9/28/2016
required for every
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed.pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board.of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
765 Old Strawberry Hill Rd Centerville MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owner's Name
information is Osterville MA 02655 9/28/2016
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria.Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3113 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
765 Old Strawberry Hill Rd Centerville, MA 02632
Property Address
Ann Williams 39 Blossom Ave. #6
Owner Owner's Name
information is Osterville MA 02655 9/28/2016
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less_than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El ® 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
El ❑ the system is located in a nitrogen sensitive.area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone'll of a public water supply well
If you have answered"yes to any question in Section E the system is considered a significant threat,.
or answered"yes" in Section D above the large system has failed.The owner or operator.of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins<3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 765 Old Strawberry'Hill Rd. Centerville, MA 02632
Property Address
Ann Williams 39 Blossom Ave. #6
Owner Owner's Name
information is required for every Osterville MA 02655 9/28/2016
page. CitylTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ElWas 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 31.0 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x3=
330gpd
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
OR Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
765 Old Strawberry Hill Rd. Centerville, MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owner's Name
information is Osterville MA 02655 9/28/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage (gpd)): 2014=144gpd2015=129gpd
Detail:
Sump.pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date i
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
<'( 765 Old Strawberry Hill Rd. Centerville, MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owner's Name
information is Osterville MA 02655 9/28/2016
required for every
ip Code Date of Inspection
page. Cityrrown State Z
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
No Records
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
765 Old Strawberry Hill Rd Centerville MA 02632
Property Address.
Ann Williams 39 Blossom Ave.#6
Owner Owner's Name
information is Osterville MA 02655 9/28/2016
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1995 Per BOH records.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
28"
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
+10'
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Line checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank(locate on site plan):
19.1
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
1500Gal
Dimensions:
4-6"
Sludge depth:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
765 Old Strawberry Hill Rd Centerville MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owners Name
information is Osterville MA 02655 9/28/2016
required for every
State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
1-2"
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
Estimated
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evi,dence.of leakage, etc.):
1500Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Covers
19" below grade
Grease Trap.(locate on site plan):
Depth below grader feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
a
Dimensions:.
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
765 Old StrawberryHill Rd. Centerville, MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owner's Name
information is Osterville MA 02655 9/28/2016
required for every State Zip Code Date of Inspection
page City/Town
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 0 No
t5ins•3113 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
765 Old Strawberry Hill Rd Centerville MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owner's Name
information is Osterville MA 02655 9/28/2016
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
0.1
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.):
H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids
carryover. No sign of overloading or hydraulic failure. Cover.6" below grade.
PumpChamber locate on site Ian
( plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
765 Old Strawberry Hill Rd. Centerville, MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owners Name
information is Osterville MA 02655 9/28/2016
required for every
State Zip Code Date of Inspection
page. Citylrown
D. System Information (cont.)
Type:
1-6x6
® leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
1-6x6 Leach pit with 4'of stone. 2"of effluent.with staining no higher than 2'. No sign of overloading
or hydraulic failure Cover 28" below grade
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
765 Old Strawberry Hill Rd Centerville, MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owner's Name
information is Osterville MA 02655 9/28/2016
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs.of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5ins•3/13 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
765 Old Strawberry Hill Rd Centerville MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owner's Name
information is Osterville MA 02655 9/28/2016
required for every
page. Cityfrown 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
v
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
765 Old Strawberry Hill Rd Centerville MA 02632
Property Address
Ann Williams 39 Blossom Ave.#6
Owner Owner's Name
information is Osterville MA 02655 9/28/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
Surface water
® Check cellar
® Shallow wells
+12'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Hand auger to 12'with no water encountered. Bottom of pit at 8'.
f
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Aim
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°y 765 Old Strawberry Hill Rd. Centerville, MA 02632
Property Address
Ann Williams 39 Blossom Ave. #6
Owner Owner's Name
information is required for every Osterville MA 02655 9/28/2016
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, Cl- 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
7I a TOWN OF BARNSTA13I E
O Id T dw ff& W SEWAGE# b
LOCATION
VILLAGEA� 1 / / ASSESSORS bw&L 0/5
INSTALLER'S NAME•&PHONE.NO?I F'V 4G `yak �A
SEPTLC TANK CAPACITY
LEACHNG FACII=:
NO.OF BEDROOMS_
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: TZA
Separation Distance Be n the:
Maximum Adjusted Groundwater Table and Bottom of-Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on-site of within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Fmpished by
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5
'77o2 TOWN OF BARNSTAB d3�'
LOCATION G� F Qw f3ft SEWAGE
VILLAGE /ASSESSOR'S MAP &LOafN 01-5
INSTALLER'S NAME&PHONE NO�ff_Q1 t)4G yoZ L Z-/,02
SEPTIC TANK CAPACITY �n 0
LEACHING FACILITY: (type) 0/,o 4V
NO.OF BEDROOMS
BUILDER OR OWNER `�c:✓vL /`(I: 5
PERMITDATE: COMPLIANCE DATE:
Separation Distance Betw n the:
Maximum Adjusted Groundwater Table and 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
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Diinpuuttl Workii Tomitrnrtiun thrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.. ........... /l ...•. o2�v...� . �.
ca\ion-i\ddress ..........
or Lot No.
..._... ................................
a
wner Address.Pf...... 5 O s
--------------- -•------•---
•-•-- -----••-•----•-•-•-•------------••--.........
nstaller Address
U Type of Building Size Lot...........................Sq. feet
�
Dwelling—No. of Bedrooms�_..-_____-_•------------------_-._Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons........---_____-___------. Showers ( ) — Cafeteria ( )
d Other fixtures ------•----------•------
----
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
x9 Septic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter---............. Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------_---_-._..- Diameter---------_--------- Depth below inlet-------------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..------------------------------------------------------------------------ Date------
TestPit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit-_-_-..-_--____.-__- Depth to ground water........................
Description of Soil
U ---------------------------------•-----------------••----------------------------------------------------.._..__.........--•---•-----•----•---
U Nature of Repairs or Alterations—Answer when applicable...._ f_. ... --.-_•_----•__--.___ \'
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compli -b "ytoard- lth.
Signed ...:......
' ce
Application.Approved By ..........` . ........ --=
Application Disapproved for the following reasons: -------------------------__--._......---.-...--..-_ '
-------------------------------------------
--------------------------------------- ----------------------------- ------ --------------:--------------- -----------------
Dale
Permit No. --------7,- .----_3c)s-------------------- 31 _77 ..?..-.�.t.........
....... Issued .. -- � �
Dace
No....7 _. � /FiEis.<��.....�b..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH }
TOWN OF BARNSTABLE
Appliration for Divi-poottl Wor1w Towitrurtiort rprinit
Application is hereby made for a Permit to Coristruct ( ) or Repair (ate") an Individual Sewage Disposal
System at
1, 4 -._.... -"'f ------------------ �Y�. 1�1""(I 1 0�
��+. o ation :Address f>< e` •ea,.......--
1 _..f�f�. - or Lot No.
�o Owner Address
a _• _-- ---------- �. --------••--- ----•-.....
ns e ur
Italler Address
U Type of B 'lding �- "'! � � .. �� Size Lot--------------- ._Sq. feet
aDwelling-`No. of Bedrooms.�..........................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type:of Building ----------- ---------------- No. of persons'.----------------......._. Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow..-----------------
low....................:...•._.........___....gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity.._..._-...gallons Length---------.------ Width---------------- Diameter---------------- Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length..........-..-_..-.. Total leaching area.._._..._.........__sq. ft.
�t Seepage Pit No..................... Diameter..................-. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date............................ -
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
(= Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.....................
-----------------------------------------------------------------------------------------------------------•--
xDescription of Soil..........................................................................
W .-- ��_ A- / .............................._r F1...l.
U Nature of Repairs or Alterations—Answer when applicable_..__ '... .. ------_ ---- C;W "
Agreement: . �,... , ../6 1` t
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance.ha beenirssued by the4b'oard of health. ' a
f
Signed -�* -
�Da e
Application.Approved By ............�1�...r<�,-,........'�_.�.....,.��-�,-
Application Disapproved for the following reasonf: ..........................
--------------------------------------------------------------------------------------------------------
.....
Dare
Permit No. .... .......:5..... ---------------------- Issued .. c c'
.. .... .. ---�---------------
Dace -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Telr#ifira e of QToraplian e
f:
THIS IS TO CERTIFY, That,the Individual Sewage Disposal System constructed ( ) or Repaired
at i�� 4-
has been,4 l............ led in accordance with the provisions of TI I'I.E 5 of The State E/n,�vironmental Code as described in
the application for Disposal Works Construction Permit No. ....._95'.- ..v....... dated ..._...................._._.----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...... . - ' Inspector .. V
J
._ .....-----�------ ---------------------- -----------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH p
TOWN OF BARNSTABLE ;
).Q1.—
Permission is hereby granted...
............ ---------------------------------
to Construct ( ) or Repair ( an Individual Se age Disposal Systterm
at No. ''�"...�/' ter"" f_+ "� n_. / a�. f n�, r .i 'f'i
.....-•- ----••-•-----�•••-f. •---•................., �e''{ rSt�eet p -----'- ___e......... ......-- ----••---.. ......
as shown on the application for Disposal Works Construction Permit No.-------- ated_____.."��-.-_C, `-9-.-`.?.........
----....•--------•-----•--------•---- ~ - -----------------------•----
/4- — 9� Board of Health
DATE •-----------------•---•-----•----•----------------••--
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
TOWN OF BARNST 2 G
0
6l w tr S E WAG E #�
�a
LOCATION
d
VILLAGE
_ASSESSOR'S MAP &L �l s
INSTALLER'S NAME&c PHONE N0
SEPTIC TANK CAPACITY -0 0
i
LEACHING FACILITY: (type) 00, GV— y tsize
NQ' 9F BEDROOMS /
BUIt.DER OR OWNER tom( `�(:t 0 S
PERMIT DATE:
COMPLIANCE DATE:
Separation Distance Be n the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility).
Edge of Wetland and Leaching Facility(If any wetlands exist '
<::::within 300 feet of,leaching facility) Feet
Furnished by
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Belk oe 44
l
• 3 , •j ,
l 'I
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---------------------------
CERTIFICATE OF COMPLIANCE
IVI.G.L. CHAPTER 148, SECTION-9 26F, �5R12
►n EY:NIS DISTRICT
Dots. _ !r j 20 17
;s that the pmperiy located ai 1a S d L(Q
AA �3
quipped with approved smoke detectors, and-&ar>,nn monoidde alarms=and wai s found to he in compliance wiih
Efts General Law, Chapter 148 Sections 26F,26FtP-)and L7 CMR 1-00 Sdction 13.7.
TEsting completed on: ( � l 1 `� '
93y.
Head Of Fire Deoerunent; CEDE HAROLL -R.
-^-_ 1lnspeatnr}
BR70—,-
mrti'c,ate eVirEs sc-4(60)days at'ter date of issue.
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SE- 1 ERS CDp PST ;1
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