HomeMy WebLinkAbout0099 PINE AVENUE - Health 99 ,Pine :S4reet
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FORM30 C&W HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H LTH
71Y/TOWN
W _
EPARTMENT
ADDRESS
GSM svey`0
_ TELEPHONE
Address _ Occupant&�� �
Floor Apartment No. No.of Occupants
No.of Habitable Rooms No.Sleeping Rooms _ V-�& 61601
No.dwelling or rooming units_ No.Stories I 1
Name and address of owner A
_
M� r emarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
f` Stairs:
J Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Re air
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
ta
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets WeiIIs Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
—Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub.-
Infestation Rats, Mice, Roaches or Other: 59YX411
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJ R "
INSPECTOR TITLE_
l I A.M.
DATE TIME P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in-violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
• """-••wri�..,,i..•ry'^'".'^�."�"r^°.i.."'�-TX�- ..�-r'��.'i-...*.�-.:.`''►.•!'r'•n',yo.+�M1^.;,"r'lvrryw.Kv+`W"y,'.f5.....3!{�,*7:Fr-wi,:>.�.si•.r•'h;ya^h`'e+./^`k..r._•�..r=N..%L�:... ,.. -,.
FORM30 CI_W HOBBS&WARREN in THE COMMONWEALTH OF MASSAC HUSETTS ,
BOARD OF .HEALTH
CITY/TO W N
W
DEPARTMENT
��M SVBy`mW
ADDRESS
TELEPHONE
_�Address 1 � � / — Occupant �
Floor Apartment No. No. of Occupants
Ld
No.of Habitable Rooms No.Sleeping Rooms— 't M^ C-4 601
No.dwelling or rooming units_ No.Stories '
Name and address of owner
1 i Remarks Reg. Vio.
YARD Out Bld s.: Fences: I
Garbage and Rubbish t
Containers:
Drainage .,
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches: ✓" r fk
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows: f t y 4
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney: `.
BASEMENT Gen.Sanitation:
Dampness:
r Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hull, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimne s:
Central ❑ Y,. ❑ N_ Equip,Re air-TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
` DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen '
Bathroom
—Pantry "
Den
—Living Room '
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4 _
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub: -,
Infestation Rats, Mice, Roaches or Other: ` ',s
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY."
INSPECTOR f TITLE
4 A.M.
DATE t TIME P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
Yta..-a
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation,or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of .
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
e
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TERMITE &PEST CONTROL 111
358 WEST MAIN STREET e HYANNIS,MA 02-601 e 771-5003
NAME ACCT.NO
ADDRESS l
CITY
asl
HOME PHONE BUSINESS PHONE
❑ Roaches ❑ Pantry Pests ❑ Hornets f
❑ Ants ❑ Clothes Moths ❑ Rats
❑ Silverfish ❑ Earwigs ❑ Mice
I' ❑ Fleas ❑ Crickets ther
_=D Spiders ❑ Yellow Jackets i
s
`Where: (BE SPECIFIC) 1 � o�=P�u
-i
I
Initial service I Last call back: 9'f initial Tech:_
MATERIAL % AMT. METHODS
4- ,
'rl
COMMENTS
:.
,a
SERV DATE t; - CORE
DQCECH CUSTOMERS SIGNATURE
Service Report Thank you
voNJLER&SONS 'ess PQgp
TERMITE & PEST CON L .�pITNEY BOWES
358 WEST MAIN S ET 02 1 P $ 000.440
HYANNIS,MA 60 0003126151 SEP 26 2011
MAILED FROM ZIP CODE 02601
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Service Call Listing By Customer
From 1/1/1999 to 9/26/2011, Status=Complete
Service Date Service Account Route lob Type-Item Duration Amount
RICHARD PECKHAM
8/26/2011 Pest Control Service 11 Inspection and estimate- Bed Bugs 00:45 0.00
8/29/2011 Pest Control Service 11 Initial -.Bed Bugs 02:00 480.00
Misc. 00:00 0.00
9/2/2011 Miscellaneous 11 Misc. - Mattress Covers 00:00 81.62 '
Misc. - Mattress Covers 00:00 91.62
9/19/2011 Pest Control Service it Follow-up- Bed Bugs 02:00 0.00
Report Date: 9/26/2011 9:49:12 AM Page 1 of 1 .
L0CA�� SEWAGE PERMIT NO.
} inr� 7- -//v+i6
VILLAGE
0 ()
INSTALLER'S NA E i ADDRESS
SOP �T Ell c
R U I L D E R OR OWNER i
rCGiA�� Qow�.� V
90/ /// lly
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
//'i✓�-g S�-
____---�
���
���� .
� �
��
. :
`�I
i
No '(/�L ~,► FRs ...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................I............................OF................... ----...............----------------•---..........---..................
Appliration for Uhipoii al Workg Towitrnrtiun runfit
Application is hereby ade for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at
�L�G�r y6)Nw/5------ -----•-------------•--------•-------......---••---•--•----------............_......------.........
................».................... .. .. ..y.. ................
capon- ddress �J Lot No.
i
Owner �ddres
��v ----.....�... .E ............................S?
........................ .......
Installer Address
Type of Building ize Lo .__.. Sq. feet
- ------------------
Dwelling—No. of Bedrooms............. ...........................Expansion Attic rbage Grinder (M
Other—Type e of Building No. of ersons...... .
Pa YP g ----...-•------------------- P ----------------• Showers . ) — Cafeteria ( )
a' Other fixtures -•----------------------•-••••••••-•.....
W Design Flow........... ..... .........................gallons per p r on r ay. al daily flow............................................gallons.
WSeptic Tank—L• uid pacity............ L th ....___. .. Width................ Diameter................ Depth.................
x Disposal Trench No.................... Width__..._...._..__ _.. Total L gth------_- -_....... Total leaching area....................sq. ft.
Seepage Pit No___________________ Diame r..... ...._._.._._. epth below inlet....._ ....._.._. Total c ' g area..................sq. ft.
z Other Distributio bo ( ) osing tank ( )
Percolation Test s Perfo d by-- ••....-••-•••----•--••----•_--------•--•-----••--•-••--- ........ Date ......................................
Test Pit No. 1 ..._.._. -_-min es ch De h of Test P .. .............. D pth to gro d water_.--____-_____-_---__.-.
Test Pit No. 2... .......... iinutes per inch Dep h of est it ................. epth to gro nd water-..--______-_-__--._.___
a -••-••-•-•• --------------••---•----••........._•-•--••--- -••----••.......................................
Description of Soil---------------------•- •-- . --- . .
V ............................•••••••--••......--•......----•-••-- •........ ...---•--------• ...._......-•-•--•-•----•-• ••••-•-•-•••......-•---•••••••-•••••---•-••••.........------•-•-•--•--•••••.
W .....................................................•••-•---•---•------- ---•••......--•- --•••----•--•. --•---• -••••-------•--•••••••--•----••--•-•......-•-•-- .........-
U Nature of Repairs or Alterations Answ w e p 'cable_... _ T�.. __._CJ^ F G......�!fi:...:�..._.��`��"G
-------------- ------
...................................... a✓.✓.. /T.
Agreement:
The undersigned agrees to install the aforedescri ed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee u d by t bo d f health.
_ � l
Signed--- ... _-- --- .... .._..._._.. C...-//a� �1_....
Date
Application Approved By......................--• t..... f ��
'lute
Application Disapproved for the following reasons: ------------------------•--•----------------------------------------------•••-•--.........---------•--
------------•---•--••---•--...--•...--•--••--•-•.....--•--•-•-----------•-------•--••---•------•...••-•---•--•--•--•---------••--••--••••----•-•-•-----------••......-••••-------....
Date
PermitNo......................................................... Issued-.......................................................
Date
No.----- -- _ Fins................,r.....
THE COMMONWEALTH OF MASSACHUSETTS '� I
BOARD OF HEALTH
...........................................OF_.......................................................--------........................
Appliration for Dispngttl Works Tonstrtir#inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (r!) an Individual Sewage Disposal
Syste�n,�at,
ram,' ��/j// ��}4
iv �.-�����7._.r...S..1 �171"try.s ................................................
/) cation- ddress or Lot No.
. �rC!'!/.� ...._....Y.:..._....................................................% �� < == -
..
Owner G.., Address
-------•---••• .:. .......... ......j..........�e�!/Y.......
��7.R�.�T
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms........... ...........................Expansion Attic ,(- j Garbage Grinder (N)
Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
alOther fixtures ---------------------------------------•---•-------------=--••--•--••••--••-•••---••-----•--•-•---•-...•-----••••....-•---•......-••-................
d
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length._--_--_---_--- Width................ Diameter................ Depth................
xDisposal 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 ( )
1.4 Percolation Test Results Performed bY.......................................................................... Date------------------------------......---.
11
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
......• --------------------•..........................---•--..........-••••--••--.....----•••.........................................................
ODescription of Soil........................................................................................................................................................................
V ...............................••------•---•-••-•---••••-•----•-••••------•••-••-••---•.....................•-•--•---••---•----•-••-•-•-••••---•----•--••---•••••-••••---•--•••---•---•-•---••..._......
w
VNature of.Repairs or Ajterations—Answer when applicable_-f--!-Dn.......O. i`_...__._-t�.1....eifi___-y.
e-r-5V'60 — 2 ........ '4arCaev n �eT.
............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been,4UuQd b t boa d f health.y
Signed--• ... .............. II
....-....
Date
ApplicationApproved By.................................. --•-••----_.•--•• ............---------
Date
Application Disapproved for the following- ..±. •••�� ................ ��
-•---....-•---•................................................•-•---•-----••----•-----.•............--__..................••••---•-•-----•••-•--...•-•••---•-•-••------•-••-----•••......----•---••------
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(Enr#iflratr of Tontplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) 'or Repaired Q
Insf ller
atcl ... 6r/``=L`-----•----��' •--•••....'� hrzt f...................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated_-..._....._...-...-.----_-.--_.-_._-.-.-_-.--.-
THE ISSUANCE OF THIS CERTIFICATE SHALf&03;AE-4e0NSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............................�Z.. /Z . L� .. Inspector.......44_:�...............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 1
......................................OF.....................................................................................
No...... J FEE.. ._
DisposalEle
orkii Tonotr ion unfit /J-
Permission is hereby granted...........................e_R ��......� ....Cf4Vt-_0-=/..................................................
to Construct ( ) or Repair ) an Individual Sewage Disposal System
atNo.................................. ................
Street T m
as shown on the application for Disposal Works Construction Permit No..................... Dated........................................... ;..
...--•-•-----•--•-------•-----.....•......---••-•••-•--------•••-----•--••-•----•••--•---•-•-
Board of Health
DATE...............................................................................
z=
FORM 1255 A. M. SULKIN, INC. S N a .r j
-Sa VS °`'
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for 30iopo5ar bpgtem Conotruction Vermtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon(X*) 060mplete System ❑Individual Components
Location Address or Lot No.qcq fNe AU�i J`� Or er's Name,Address and Tel.No.
K\ l
Assessor's Map/P cel hn 1.5 i�� ?C�VZ W
Ito ay\o
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
C �J
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Algat !1� ryts h !yi yC',q k
s .
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenano of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of t En ' ental Code and n to place the system in operation until a Certifi-
cate of Compliance has been issue is o d
Signed Date
Application Approved by Date �J`Application Disapproved Disapproved for t e fdf owing reasons
Permit No.20a"I — Date Issued
I
No. 00,;L—5�11 Fee V5, 00
THE COMMONWEALTH'OF MASSA"CHUSETTS Entered in computer:
Yes
(PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE., MASSACHUSETTS
i
Application for Migoar *p9tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon(�O 21complete System El Individual Components
Location Address or Lot No.aq `�tr je ��,� Owner's Name,
ce ammme``,Address and Tel.No.
Assessor's Map/Parcel N� a7) MCA n An
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
C V\
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
1
Size of Septic Tank. Type of S.A.S.
i
Description of Soil !
Nature of Repairs or Alterations(Answer when applicable) Alon Ylcicwj f 1 S 1`I4ci !�e/D k__
} Date last inspected:
r.
_,- Agreement:
y• The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of th En io e�ode and npt to place the system in operation until a Certify-
rate of Compliance has been issue,.by't��Bo,
Signed ri' Date /� s-Gd`
Application Approved by Date 5- -G")-
Application Disapproved forte fkwing reasons
Permit No. �2001; ' Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
A " BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS�CERTIFY,that the On-site Sewage Pisposal System Constructed( )Repaired( )Upgraded( )
Abandoned(V)by W ll
at '_ t ?4? Old /�Veg.,/ 9%S has been constructed in accordance
v a
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 U0.2-'V 7 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the sy stem,��will functi s designed.
Date IQx11x11,01. Inspector ' ";�� J I '+
v
---------------------------------------
Fee J
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLEsrMASSACHUSETTS
1wigpoot 6potem Construction Permit
Permission is hereby granted to Construct( )Repair( )'Upgrade( )Abandon
System located at hI N AUF .
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title S and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: 1 I —U 5—O Z Approved by_h�ck, w 0 C `�wt