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HomeMy WebLinkAbout0035 QUAKER ROAD - Health 35''QUAKER RD., HYANNIS TIGr�R PAINTING CO. iq= 3 f®`30 R ° a a � o or a S2J�RECYCCFp Om UPC 17734 No. 2-153CR °osr.coNS���� HASTINGS. MN i 1� 70 —3y 110610 3 b o o � t �h ---TOW-N OF-BARNSTABLE 'GO A - - t I LOC» .�TION G � n _ SEWAGE # I VMLAGE 1'�`1 A1-4Jt S ASSESSOR'S MAP & LOTJ�/0°- 5 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I ,?kn GCS i,h LEACHING FACILITY: (type) QO (size) (0" Xlpt 1 .0 NO.OF BEDROOMS 3 Sub BUILDER OR OWNER 'CatrQ PERMITDATE:�I I j�� COMPLIANCE DATE: �� r4 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 1 2 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge tof Wetland and a hing Facility(If 5 e d exist within 300 feet o leaching facility) _ Feet Furnished by. N4g i SKETCH OF SEWAGE DISPOSAL SYSTEM i 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 Locme where public water supply enters the building. Swing Ti QUAKER ROAD ;k A- Tank In—21' B- Tankln-23' A—D•Box-32.5' B—D-Box-21.5 A—Leach Pit H I—54' WarerriLine B—Leach Pit NI-28.5' A—Leach Pit N2-28' B—Leach Pit#2-30' I Exist House A ..... B Septic Tank!. t (1000 Gal.). ,a. .,� D-Box Leach Pit ql . °- Leach Pit N2 TOWN OF BARNSTABLE Date/0 TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: C-r p PV;'RPC-C r 'T.gco, 3V �BUSINESS LOCATION: k � ,Mh ,gn INVENTORY MAILING ADDRESS: 3 5 p, 1i_� R� ,,IN'i5 , t-�k,o� k TOTAL AMOUNT: TELEPHONE NUMBER: 50-2 3G4 Jla% CONTACT PERSON: :1,(�0_V- I A,*)U-y EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: Fire (District: Waste Transportation: Last shipment of hazardous wasted. 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 re uires 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. 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) 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 Qp UA L;y; n0.ih� lof 'CA� C�S��2t aS Laundry soil &stain removers ' (including bleach) ` LL Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash I WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Slinature Staff's Initials Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/1.5/12 page. Cityrrown 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:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: D key to move your cursor-do not Brian Reyener use the return Name of Inspector key. rT Ranger Construction Company Name 46 Crowell Rd. Company Address 4 East Falmouth MA 02536 City/Town State Zip Code 508-274-9753 SI 13242 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address nd that 1 p information reported below is true, accurate and complete as of the time of the insp_41tion. The InspeRmn was performed based on my training and experience in the proper function and m5JhI nance afcpn si sewage disposal systems. I am a DEP approved system inspector pursuant to Se Aion 15.340of- Title 5(310 CMR 15.000).The system: ' c� 1 tat C= ® Passes ❑ Conditionally Passes ❑ Fails rn r ❑ Needs Further Evaluation by the Local Approving Authority 10/17/12 Inspector's Signature 0Date 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. t5ins-11/10 Title 5 OffiVInsF.. urface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 page. Citylrown 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 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 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): Lt5m. 1110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owners Name information is required for every Hyannis MA 02601 10/15/12 page. Cityrrown 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): I 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-11/10 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 M 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 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 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 1/2 day flow t5ins•11110 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 a , 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 page. CitylTown 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. El ® 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. ❑ ® 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M > ' 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-11l10 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 VoluntaryAssessments M 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Existing 1000 gallon Septic Tank with a 2 6'x6' pits Number of current residents: 4 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 Last date of occupancy: NA Date 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 1 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: NA Date Other(describe below): f General Information Pumping Records: Source of information: NA 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 1 ❑ Shared system (yes or no) (if yes, attach previous inspection records,lif 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•11/10 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 �M 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 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: Septic Tank and Leaching installed about 30 years ago Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4.5 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments(on condition of joints, venting, evidence of leakage, etc.): Good Condition Septic Tank(locate on site plan): Depth below grade: 4.0 feet Material of construction: ®concrete ❑ metal El 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: Sludge depth: 4" t5ins•11/10 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 GM , 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 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 NA Scum thickness 10" Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition . Liquid level is correct.T's are intact Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 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 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 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-11/10 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 M 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 page. Cityrrown 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 NA 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 in good condition 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: SAS in Good Condition t5ins•11/10 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 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner owner's Name information is required for every Hyannis MA 02601 10/15/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2- 6'x6' ❑ 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.): SAS in Good Condition 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 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.): SAS in Good Condition I 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•11110 Title 5 Official Inspection Form:Subsurface Sewage pisposal System•Page 14 of 17 Commonweailh of Massachtmeft �i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Quaker Rd Hyannis MA Property Address P.Giannakopoulos Owner Owner's Name requ for is Hyannis MA 02601 10/15/12 required for every page. Citylrown State Zip Code Date of Inspection D. System information (corn.) 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 2 ; �S.o 7 e 26. 0 3Z 28..E l i { � t5ins-11Ho Title 5 Offidal kspedim Form SOmiace Swrage Dbp*l System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 page. Cityrrown 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: 10+ 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: 1979h 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: Local Perc Test results showing no ground water @ 10+ below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Quaker Rd. Hyannis MA Property Address P. Giannakopoulos Owner Owner's Name information is required for every Hyannis MA 02601 10/15/12 page. Citylrown State Zip Code Date of Inspection' E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked I ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed 4 ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i } f t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 t--, �-• Date:, / 1-1 / t D TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: L`- S BUSINESS LOCATION: Z) INVENTORY MAILINGADDRESS: Z,_ Q-%­1A�C'ZA? QA i� iA��S _ ( 1rI TOTAL AMOUNT: TELEPHONE NUMBER: S0'— Z a? — 156 2— CONTACT PERSON: 1Sd K C© 2 4Z)\1AaS�Z EMERGENCY CONTACT TELEPHONE NUMBER:_, ��' s Z9 2 — ®� �, MSDS ON SITE? TYPE OF BUSINESS: CAR— Q A Z t-i ` k 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 materials 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. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. 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 Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes 1-Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS I TOWN OF BARNSTABLE Date:. TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: Pe rAG L.L 4oc-1 Glti BUSINESS LOCATION: 39 aLt kkE12 P-r) INVENTORY MAILING ADDRESS: 351-- Q_wF1_,E,R.. 1?h TOTAL AMOUNT: TELEPHONE NUMBER: 5-08 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: petih INFORMATION/RECOM MEN DATI NS: 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 materials 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. Observed/Maximum Observed/Maximum _ Antifreeze (for gasoline or coolant systems) _ Misc. 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 Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. 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 (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers I S Qh 4h leUnr�1L �DrP � va I (including bleach) }� (� Wi l\-tit nVhC�y Der nu S Spot removers&cleaning fluids U U (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS � l � . t� t � I� r�- -- __= s FORMl30 C&W Hoses&WARREN'"' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE CIT /TOWN W DEPARTMENT ADDRESS ^M SVBy`0W TELEPHONE f / Address �C. — Occupant ApfV Floor Apartment o. No.of Occupants No. of Habitable Rooms Z5 No.Sleeping Rooms No.dwelling or rooming units--No Storie Name and address of owner emarks Reg. Vio. YARD Out Id s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: 21— STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: Tap ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: = Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: ° Central ❑ Y ❑ N E ui . Repair — TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: on ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outl s Wa Ceils. Win Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom(1).. 6U Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted 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 REPOR S SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY INSPECTOR TITLE DATE TIME ®° " — P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. J 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. � �' /'T f r'y�'-�;'�--��.'�^•.`^^'a►+r^'°•+wns'F"w.'.....""..'.r•w.:"'.,tr,^"'T`•^'-".^^r'T*'.,,'n'(ro`4"T.^T�wa'°r"Mrr^'4r+"w.,.c*>...e,,,+4....`.,`}�.'�,•�-.,.rrw. v."Y `"1�+k. "F ' 1"' TM THE COMMONWEALTH OF MASSACHUSETTS s FORM 30 C&w HOBBS&WARREN r. BOARD OF HEALTH CITY/TOWN W DEPARTMENT G1M y' o ADDRESS TELEPHONE Address — Occupan Floor Apartment No. No.of Occupants No.of Habitable Rooms_ - No.Sleeping Rooms No.dwelling or rooming units No.Stories Name and address of owner "2 C) � Remarks Reg. Vio. YARD Out Id s.: Fences: Garbage and Rubbish Containers: Infestation Rats or other: l STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: _ r Roof N "' Gutters, Drains: t. Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: J t Stairs: Lighting: V 1 STRUCTURE INT. Hall,Stairway: Obst'n.: r . ' Hall, Floor,Wall,Ceiling: A Hall Lighting: Hall,Wiridows: . _ t _-HEATING 'Chimneys:' i- Central ❑ Y ❑ N Equip. Repair .—(� `''✓ r TYPE: Stacks, Flues,Vents: 1 v PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: Q 4 'I H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: , ❑ 110 11220 Fusing,Grnd.: �) • �. AMP: Gen.Cond. Distrib. Box: �.- { j Gen. Basement Wiring: DWELLING UNIT I Ventil. L to Outlels Wally Ceils. Wino. Doors Floors Locks _ Kitchen ��, ' V Bathroom _ J Pantry ' Den -� Living Room A Bedroom(1). Bedroom 2 Bedroom 3 Gql +fi¢ Bedroom 4 r A/L C V .Hot Watelr Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub.- Infestation Rats, Mice, Roaches or Other: Egress Dual,and Obst'n: General Building Posted 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 REPOR AS SIGNED AND CERTIFIED UNDER THE PAINS AND i PENALTIES OF PERJURY." INSPECTOR TITLE DATE 1` 30— TIME 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. 'Y-w.'K..��.�'--,_.�^—y,twi,^.�-'�'. +....�._.::;�.r.�g��""r'y.�_'`.",_'"•'"y...++R'*v""'"''x�r'"i;rY++.,+^5a,�'�^►'�''°r.,/'*w.°""^•""",,."""ti#"v�"°"pw:�'+'y'!''��r°n+.h.f*r,r.,..s�.""'�n+'"u"'ivry�r+d+s�„�,,,'.,�r{+v ~FORM30' H&W HOBBSBWARRENTM THE COMMONWEALTH OF MASSACHUSETTS C BOARD OF HEALTH_ CIT�/TOWN W {rr DEPARTMENT ADDRESS TELEPHONE f. Address �, J "'�° ��'; Occupant _ Floor Apartment No. No. of Occupants__ ) No.of Habitable Rooms —No.Sleeping Rooms No.dwelling or rooming units No.Stories Name and address of owner �r fi 1 p Remarks Reg. Vio. YARD Out 8Id s.: Fences: Garbage and Rubbish Containers: AA �v��►�( � r Drainage , ; �. Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual E ress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: _ Roof ► Gutters, Drains: Walls: Foundation: Chimney: ` BASEMENT Gen.Sanitation: Dampness: i + } Stairs: (� _ - r Li htin : 11 1j V i ..�.' STRUCTURE INT. Hall,Stairway: j Obst'n.: Hall, Floor,Wall,Ceiling: Hall Li htin i Hall Windows: -_::�HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair (� TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: n H.W.Tanks Safety and Vents '' ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: .n, W AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: � DWELLING UNIT Ventil. L to . Outlets Wall Ceils. Xint I Doors Floors_ Locks Kitchen r;� ,�-4 i 'E-•--�I Bathroom V Pantry Den Living Room 4, Bedroom 1 n Bedroom 2 ?61) Bedroom 3 4)r f- m , Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub.- Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted 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 JS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY f l INSPECTOR TITLE DATE ^' TIME 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. FORM30 C&W _ HoeRs&WARREN ren THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN W L-1�A a DEPARTMENT 'p ADDRESS `y(l Q. y//�/��., PJ �/� GSM svey`e so g &" G_— 4 qq TELEPHONE Address ` �� Occupant �Ce V YL -� Q� N �\1 Floor -�' Apartment No. No.of Occupants No. of Habitable Rooms—A_0 No.Sleeping Rooms __ No.dwelling or rooming units A. No.Stories 2— Name and address of owner �'t N e 4- 62 viw- I A nv nr A 14 Oraou 0S k 2>6 L. o L;l VA g�0 C f �iZ>f,Q V�(.�sL O Zto �, Remarks Reg. Vio. YARD Out Bld s.: Fences. Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: tA cl YZAI p3 Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof V�- I— T.iC Y2 t-jo-1 Cl t a.- 'y 0 Gutters, Drains: Walls: Foundation: Yn Chimney: _ Eslt S7�nib BASEMENT Gen.Sanitation: Dampness: 4r.. Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: r;_S- r NCx (,1uot.4- '( CEc..40 t-S Hall, Floor,Wall,Ceiling: 3-0-CS Hall Lighting: a- Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pant Den Living Room k1kq ` 4 =aterF ' v ¢- l `Z S� Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: General Building Posted Locks on Doors: 1,gT c 0 A-S `mu 170 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 P JURY." INSPECTOR S TITLE %Q S 7U fL V V DATE D�1 TIME 2'bo P. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 1 410.750: 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. �`r—`�(_rf'.,_.,---.,..Y V'..-':-.-_-+.Tr«-.�.-�..-•-_rw--_+.r-.........-._.-..�v +.,;x..o .v.Thn�.w^..��tiw'+`ma..../� ya+�" ''.� i-y„re FORM30 &W HoeesaWnaaeNTM THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OF HEALTH CITY/TOWN o DEOAR,TMENT ADDRESS' ,M s `Ca F � Z— �iCnYc� "7 �V AT 1.1, TELEPHONE Addre A,+s V-AA_ -Occupant M_ 6-0- � 7-\j Floor � Apartment No. No.of Occupants—_2 No.of Habitable Rooms No.Sleeping Rooms_62 No.dwelling or rooming units 44L No.Stories', r �+ Name and address of owner rpn;t 14 t rf_ l���L� A� ooe_oS C1r N- 2\Jt4l-JL, t.'t/� O1(semarks Reg. Vio. a YARD Out Bld s.: Fences' j t* Garbage and Rubbish # Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: tsk Cra YZA, 1„% o,/0 mo Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: C.—M Roof Gutters, Drains: Walls: Foundation: .� Chimney: '' Q - �",�� S7/nN BASEMENT Gen.Sanitation: q F(A 9- CC I_r 4� �.. f Dampness: Stairs: ?_ Li htin : STRUCTURE INT. Hall,Stairway: 0bst'n.: S itJ SN�1uV4- 5'rVC-r0tLS p Hall, Floor,Wall,Ceiling: iyd 13 A S r-t- -j I U l Hall Li htin : F�j(Z— Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS _❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry t, Den Living Room _ ij. 1 7W Fyn . .Bedroom(1). 1 , Bedroom 2 �� m Bedroo 3 'Bedroom 4 jCA Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent. Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats,Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: KA 12¢C.1 'C t 0 A S rN 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 c S. TITLE S y�0-4."[U�L zI� A M. -DATE V 12 L/0 s ` TIME P. f. 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 II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both-hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. M i �- Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments , c -1 SubsurMca Sewage Disposal System Form �( inspection results must be submitted on this form or on the official Title 5 inspection Form dated 6f1512000.Inspection fauns ma not be altered in an A. Certification I .� When tit out 1. Property Information: 1form an the C®�� use _ ..�,.S 1...6 c�n oNy the tab key Ad --to move your itcS 03�.,, use the relum NMID �-- -- key. S Address s City/Uawn f S 0 .1 code Date of Inspection: rl j Date � G o�2 ; N Of 1 j env s l.s'f 6convarl `) y Name . l(,*' -4 ,e ,1 rye- -zip Code 11 s. N Number CewtMcation Statement: !certify that!have personally inspected the sewage disposal system at this address and that the Pe�information reported below is true,accurate and complete as of the time of the inspection.The inspection �ed 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 45.340 of Title5,(31100 CMR 15.000).The system: [�t'asses O Condidomity Passes 0 Fails ❑ N c YE n Local Approving Drily e Signature Date The system inspector shag subm a copy of this inspection report to the ApProvin9 AI ority of Health or DEP)within 30 days of completing this inspection,ff the system is a sh or has a design flow of 10 O()0 gpd or greater,the inspector and the _ report to the appropriate regional office of the DEP.The sysfiem owner shaA submit and copies sent to the pp o��should be sent to rW sYcte wne buyer,if applicable.and the approving authority. ;{ t '"""Thts report only describes conditions at the time of inspection and under thetxdltlom�pof uaeatthat time.This inspection does not address how the system will perform in ponder' the same or different conditions of use. t5kUp dot•11r.WN TMO 5 Otridai hmpecWn Form:Subsorrhm Sewsw to nr �RPaw I of 16 r Commonwealth of Massachusetts Title 5 Official Inspection p n Form Not for Voluntary Assessments Subsurface Sewage Dismal System Form A. CertM 'on (cons) eL 1�� 2 rew *tlS �� no� o $Na" ��� � , Date or ton/ inspection Summary:Check A,B,C,D or E/ahwys complete all of Section D A) System passes: have not fiDund any information which indicates that any of the failure criteria in 310 CMR 15.303 or in 310 CMR 15.304 exist Indicated below. failure criteria not evaluated are Comments- _ B) S Conditionally passes: ❑ One re system components as described in the"Conrepditional Pass'secrtion need to be the lBoard of aced aired imp 1 Pass- system, completion of the replacement or repair,as approved by Answer yes.no or Trot ad (Y,N.ND)In the❑for the following statements.if"rtot determined,"please expEJ / The septic tank is metal and o 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits su I infittrallon or exfiltm*m or tank failure is imminent. System will Pass inspection if the wd . tank Is replaced with a compMng SgAc tank as approved by the Board of Health. *A rrietal septic tank will pass inspection if it is rally sound,not 1 ealft of Compliance indicating that the tank is less than 2 ars old is available. and if a Certificate ND Explain: Mmp doc•1112004 Me 5 ofikW Impecl m Form SWmafaw Sw sgeObposaSystem Pap 2of18 . Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cunt.) e � (::?92 Hai =�?5' � cloZip Code Owners Nang Date of 1 B) System Conditionally Passes(cont): ❑ Observation of a backup or break out or high static water level In the distribution box due to broken or obstru pipes)or due to a broken,settled or uneven diisirtbution box.System VAR pass inspection if(with of Board of Healthy ❑ broken pipes)are laced ❑ obstruction is removed 14 ❑ distribution box is leveled w ced ND Explain: - i ❑ The system required pum ' more than 4 times a year due to broken or obstructed pipe(s).The system wilt Pass inspection (with approval of the Board of Healthy ❑ broken pipes)are rep ❑ obstruction is removed A)l ND Explain: C) Further Evaluation is Req by the Board of Health: ❑ Conditions exist which regeme evaluation by the Board of Health In order to determine If the system is tatting to protect pu health,safety or the envlronmertt 1. System will pass unless Board ealth determines in accordance with 310 CMR 15.503(7)(b)that the system Is not fun ing in a manner which will protect public health, safety and the environment ❑ Cesspool or privy is within 50 feet of a surface ❑ Cesspool-or privy is within 50 feet of a bordering vegetated wetland or a salt marsh { Skisp doc•MAN AN Title 5 Olf W inspecUm Form:Subsudace Sewage Disposat system Page 3 of 16 i ' h Commonwealth of Massachusetts Title 5 Official. Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cons) s PMPIVAd&Wc3 q AV A/,': /%JF rtL�— 7�0 "IP cone owner's Name Date of YNwiW C) Further Evalu on Is Required by the Board of Health(cont.): 2. System will fail u ess the Board of Health(and Public Water Supplier,if any) determines that the tem Is functioning In a manner that protects the public health, safety and enviro ❑ The system has a c tank and soil absorption system(SAS)and the SAS Is within 100 feet of a surface ter supply or tnImAmy to a surface water supply. ❑ The system has a septic and SAS and the SAS Is within a Zone 1 of a public water supply. ❑ The system has a septic tank and S and the SAS is within 50 feet of a private water supply wen. . ❑ The system has aseptic tank and SAS and a 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,perforated at DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that wen Is free from pollution from #hat facility and the presenoe of ammonia nitrogen and nitrate n' is equal to or less than 5 pp provided that no. farlure a iteria are higgered.A copy of analysts must�attached to lids fbim. 3. Other. t5 wp.dw•112004 TWO 5 OWW I rspec8on Form:Sutouisoe Sewage Disposal System Pap 4of16 Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certifi tion (coat) .7s-Z JA RA & A40 601 see O�'s Name Darr of bopecow D)System Failure Criteria Applicable to AN Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ 14 Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool y� Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool Q Liquid depth in cesspool is less than 6'below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to dogged or obstructed p4*s).Number of times pumped: Any portion of the SAS,cesspool or privy is below high ground water elevation. I 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 pubfic weR. 0 tq �Portion of a cesspool or privy is within 50 feet of a private water Supply Any portion of a cesspool � � from a private water sy well with no ac or Is ceptable�than 1 feet but greater than 50 feet cxeptable water quality arnalys [This system passes If the well water analysis,performed at a DEP certified Laboratory,for coNform 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 PM Provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No The system fails.)have determined that one or more of the above fallute c'it8d3 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. 151nW doc.a MAN TWO 5 0 r . Form:Subsurface Sewage pisposai pap 0at16 1 " a Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Ceri ication (cost) 5 v 4 1<e-q- (�oA 0,2 e oil zip Coft Ownees rye gate of k pedion E) Large Sys : To be considered a large system the system must serve a facility with a design flaw of 1 000 gpd to 15,000 gpd. For large systems. must indicate either'yee or"no"to each of the following,in addition'to the questions in Section YES NO / ❑ ❑ the s is within 400 feet of a surface drinking water supply ❑ ❑ the system with1n 200 fed of a tributary to a surface drinking water_suppiy Q0 the system is in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a pped Zone If of a public water supply well If you have answered'fires'to any question In E the system is considered a significant threat, or answered'°yes"in Section D above the large s has failed.The owner or operator of any large system considered a significant threat under Section or fate 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. l I t5nsp doc•1 MAM Tdie 5 OWWW'h ;x3ch ►Form Subaurrece Pages Of is } •,C Commonwealth of Massachusetts .W Title 5 official Inspection p Form Not for Voluntary Assessments Subsurface Sewage Disposal System form B. Checklist MOMSVp Code - -� ownees Mauve Date OfkAmcoof- Check if the following have been done.You must indicate"yes'or"no"as to each of the folks ft: 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?(f they were not available note as WA) ❑ Was the facility or dwelling inspected for signs of sewage back up? . ❑ Was the site inspected 1br 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? �y ❑ 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 relates to Part C is at issue apProxhnation of distance is unacceptable)1310 CMR 15.302(3)(b)3 t`rsPA0C•11/2m Tft 5 OftW t Form:Sut>.aurrace Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information v I state code owners of Residential Flow Conditions: Number of bedrooms n Number of bedrooms(actual): DESIGN flow based on 310 CNiR 15203(for example:110 MA x#of bedrooms): 1 C3 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? 0 Yes jy No Water meter readings,if available(last 2 years usage(gpd)): —a¢—=-S Sump pump? ❑/ Yes No Last date of occupancy. -71 t am 0 bate CommerdaUlndustrial Flow conditions: Type of Establishment: Design flow(based on 310 CMR 152m): carons per day tam Basis of design flow(seat&Vetsons/sq.R,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—Data ata Other(describe): 15inv.doc•11/2M4 TWO 5 Offthd Inspection Form:Subsudaoe Sewage okpasai System PageaOfl6 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System 1 formation Mnt) 77=1,1, Z) State zip coda S Daft-of InspepiGn General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes [�No If yes,volume pumped: $ How was quantity pumped detemnined? galm Reason for pumping: Typeo Septic tank,distribution box.soil absorption system ❑. Single cesspool ❑ overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if arty) ❑ Innovative/Aitemative 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 i"ited(if known)and source of Information: 7 VPP,-1 S 0 Were sewage odors detected when arriving at the site? ❑ Yes No t sp doc•1 i/200d TWe 5 Otfidai rnspecftn 6orrrr:subsurface Sewage 06VOsasystem- Page 9 of 16 i f . . Commonwealth of Massachusetts Title 5 official. Inspection- Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information cunt) Property Ad4m J.J / . Z1`Ade OWroes Nance Date of Building Sewer Q:[0]40PVC on site plan): Depth glow grad feat Material of constru ❑cast iron other(explain):Distance from privter supply well or suction feetComments(on conof joints.venting.evidence of Septic Tank(locate on site plan): Depth below grade: feI V et Materialof construction: Q)X11lo ete ❑metal ❑fiberglass ❑polyethylene ❑other(e)tplain) If tank is metal,list age: yam Is age confirmed'by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes 0 Pb Dimensions: /C?C`� 0 Mudge depth: — 3 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet flee or baffle Haw were dimensions determined? t5kWP doe•1 UMN TWe s orrrchd tnsPec5m Forst:S<+bwtaoe Sewage Disposal System Page 10 of 16 . - Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information cunt. �- v Aleei j Citq state 11P Code Owners nfne Dane or Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integ►tiy, liquid levels as to outlet' evidence of leakage,etc.k Grease Trap(locate on site plan)_ Depth below grade: JY> feet Material of construction: r ❑concrete ❑metal ❑fiberglass ❑polyethytene ❑other(explainj: Dimensions: Sctun 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,eta): Tight or Holding Tank(tank must be pu t ti of k spedlon)(locate out site plan): Depth below grade: Material of construction: [I concrete ❑meta! ❑fiberglass ethylene ❑other(e)p?ink Omp.doo o 112101 TAte 5 Official k"ection Form:sutoufave Sewage Dkposal Sysigm i` pop tt or as Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information t) see 27P coft owners Name --�— -' Daft or Tight or Holding Tank(cont.) Dimensions: Capacity: � gallons Design Flow: t per day Mann present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes❑ No Date of last pumping: — Date Comments(condition of alarm and float switches,etc.): Distribution Box(if present must be opened) e(locat site plan): Depth of vqu➢d level above outletinvert Comments(note If box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage Into or out of boot,etc.): a �-Yo Pump Chamber{locate on site plan): Purrs in working order. ❑ Yes [] No Alarms In working order. ❑ Yes ❑ No tmw.doc•f i/Ztir)4 Tide 5 Of W hnspedWn Form;Shape 80WV9 DbPOW Sy dwn Page 12 of 16 Commonwealth of Massachusetts Title 5 Off cial Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) ������ Ke�( k�o� > gad 7vrV'- ��/ S- �e �(-S r��( v/ state Tap Code -�� Owners Name Date of Inspe n Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): t located,e> in why: /_ r/> t0 Y 1 � �� �(P Type: 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.): t5insp.doc•11/2004 Me 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 official Inspection. Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cons) P Address 14 te Code Owners Nate Date of 1 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 �1✓ 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 o ponding,condition of vegetation. etc.): t5inspdoc•11/70Q4 . - Tdfe 50fflcW1 rqscun Farm.Subsurface Sewage DbposW sYsLem Page 14of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal.System Form C. Syste information (cont) �� t, _^ 1 o2&v state �' �Code Owners Nam date of 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 entem the budding. oto A oto (` 0\1 j o le- 00, ,lle 5 OfT�Inspection Fora:Subsurface DbposW Sysn,- Page 15 of 16 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property dress cityrro state � "`� � Zip Code Owner's Name Date of Inspectiop( Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: fi7 ? Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board iealth-explain: -P ®CA.) Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You pyst describe how you established th high grou water elevation: (N r�- Q e- CcJ}!eu t5insp.doc•11/2004 - Title 5 Official Inspection Form:Subsurface Sewage Disposal system Page 16 of 16 �y IL a 05/21/20DS 09:14 IPennichuck hater Works �PG I starck U/B CONSUMPTION HISTORY REPORT _ _ - -- - - -- ubcnsin ~O ` 0 ACCOUNT # CUSTOMER NAME PARCEL ION STATUS r) SERVICE MAN METER # CD READ DATE TIME BY BILL # CURR READ USAGE REPL USAGE CHARGE ANT BILLED AMT ------------------------------------------------- --------------------------- --------'Or; P-------------------------------- Q 61614 LAURA MENESES-OST CHUK 320306 35 QUAKER ACTIVE HYQCON- 1 HYQCON 059933054281 F 02/29 2008 834703 1,789 0 0 .00 2.69 ® HYQCON- 1 HYQCON 059933054281 A 02/20/2008 815471 1,789 1400 0 22.68 49.62 U5 HYQCON- 1 HYQCON 059933054281 A 11/16/2007 741029 1,775 3500 0 57.17 84.11 HYQCON- 1 HYQCON 059933054281 A 08/14/2007 666663 1,740 6000 0 87.00 109.80 HYQC0N- 1 HYQCON 059933054281 A 05/22/2007 594851 1,680 15400 0 223.30 246-10 HYQCON- 1 HYQCON 059933054281 A 02/12/2007 518145 1,526 83 0 120.35 143.15 HYQCON- 1 HYQCON 059933054281 A 11/15/2006 445994 1,443 16 O 23.20 46.00 HYQCON- 1 HYQCON 0599330.54281 A 08/14/2006 373429 1,427 18 0 26.10 49.90 HYQCON- 1 HYQCON 059933054281 A 05/16/2006 238282 1,409 13 0 .00 .00 HYQCON- 1 HYQCON OS9933054281 A 02/15/2006 9865026 1,396 D 0 .00 .00 4f END OF REPORT - Generated by Jayne Starck w+ W Ln ul Cl Z Z 2 N m m a) m m N ru Q . Town of Barnstable Regulatory Services BARNSTABLE. ; Thomas F. Geiler, Director MASS. Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 v REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving . this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction,Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:ISEPTIC\Disclaimer Private Septic Inspections.DOC of YHe Town of Barnstable r� P� o Regulatory Services SA"STABLE. : Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical .observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction,Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:\SEPTIC\Disclaimer Private Septic Inspections.DOC I COMM(,_ WEALTH OF MASSACHUSETTS EXiCOTIVE-OFFICE OF ENVIRONMENTAL AFFAIRS d JDEPARTMENT OF ENVIRONMENTAL PROTECTION � �O`• I .7. _F�i 'n'Se :C".j i i .1• <° i �'. Jr+- TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: #35 Quaker Road Hyannis,MA Owner's Name: James&Laura'Ostanchuk Owner's Address: 35 Ouaker Road Hyannis, MA 02601 Date of Inspection: 12/05/05 I-i T i. h ft Name of Inspector: (please print)iMr' !&armen`El Company Name: CAPEWIDE ENTERPRISES,LLC Mailing Address: .._ P.O.-Box 763 Centerville.MA 0632 n ( Telephone Number: (508)-428-4028 c CERTIFICATION STATEMENT I certify that I have personally inspected the`sewage disposal system at this address and that the info ation reported below is true,accurate and complete as of the'time of the inspection.The inspection was performed ased only f� training and experience in,the.propertfunction andamamtenance,of on site�sewage disposal systems. am a DEP approved system inspector,pursuant to�Sepction 15 340 of Title 5(310,CMR 15.000).^The system: XX Passes �ggSs9 Conditiorially.Passes: : 't`,. <:� ' RM c� CAEN � e urther Evaluation by the Local Approving Autho •y E. 'is i8 SHAY Inspector's Signature:,, �: [ „„, c�. hll Date: 12/05/05 RTtF �oP �F5 lNSPEG The system inspector shall'submit.a copy-of this'inspectionre rt to the Approving Authority(Board of Health or DEP)withim30 days of complefing•,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 t&systemWwiie 'andicopies sent to the buyer,if applicable,and the approving authority. Notes and Comments Leach Pit#1 has been hydraulically failed and replaced with Leach Pit#2 as an overflow. No evidence of hydraulic failure noted in leach pit#2. .4°effective depth available in Leach Pit#2. Riser present on both leach pits. . t; ` f'a, I l.:!li:."•`t. ''.,_ , k^ ****This'report only describes lconditions,atilthelime'oflinspection4and under the conditions of use at that time. This inspection does'notiaddress-iiiWthe'system will Perform'in-the future under the same or different conditions of use. '`; , .,C ,!:`•'::,:C(tl'`il illiJl i.%..�ii! 4t I '1.,. '{(i t '".I.: . r Title 5 Inspection Form 6/15/2000\' =''!'! i'"s`s • page 1 ��)i t y ry r < Page 2 of 11 r OFFICIAL INSPECTION,•FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEMISPOSAL SYSTEM INSPECTION FORM i PART A =F Y-CER,'IFICATION-(contiiiued) . Property Address: #35 Ouaker Road Hyannis,MA Owner: James&Laura Ostanchuk Date of Inspection: 12/05/05 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: , B. System Conditionally Passes: One or more'system coniponerit's as described in the;`Conditional Pass?section need to be replaced or repaired.The system,upon completion of the replacepient 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 methl�and.over 20•years old*'for 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 complymiz-septic stank as,approved by,the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not'Icakmg and if a Certificate of Compliance indicating that the tank is less than 20 years old,is available. ND explain: ` - � w 1 ; ,w- 1:.Ilin!1 , onAviltCE1 :a ;ii., - '. � o ' ' " •':.I •i un 'gill rr •.' .:� Observation of sewage.backup or.br'e outi 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)': "'`' �h L--broken-pipe(s)-are replaced == --- ------ obstruction-is removed' distribution box is leveled or replaced ND explain: r: " The system required pumping more-than 4 tones a year due to broken or obstructed pipe(s).The system will pass inspection if(with'approval of the"I III( Health): i t broken pipe(s)are replaced f - •, is�1f .,.,ii�i'i i:.:�u , t t ,i=.? L_ T "Ii i:11 d, obstruction is removed ' met,li alid o%er,20 �c � ,r+l l or the ND explain: r,.,111rLlU.,I,JI I,,,. I:Ii,,,_ .a f l ,I A. pWl '11'_' r'w oid.ail`i ?I..i .�'. - a•..s�'�.-fit.I �� ' ,i �t ..;��\i ItPt..ate�<-l'�l #a�!'� {, 1 i.�(.,i•.e; � .� �, - ? ,,,... - 1 Page 3 of 11 x . ,A 1 ., l!I Litt stuirt : M NOTF ORVOLUNTARY ASSESSMENTSOFFICIAL INSPEGT1IOlN-F9 SUBSURFACE1SEWAlGlE aD, I,SPlOSAL SY-STE\M INS PE1C,TION FORM i?ART A . I � kC; TFICATION continued) Property Address: #35 Ouaker Road Hyannis,MA Owner: James&Laura Ostapchuk Date of Inspection: 12/05/05 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 mariner 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 feetr=�of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board oflalth(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-aid-poil-absorption system(SAS)and the SAS is within 100 feet of a surface water supply pry�nbutary(;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 aseptic tank;and.$AS{•and:the SAS is within 50 feet of a private water supply well. The system has a septic tank arid:SAS and the SAS is less than 100 feet but50 feet or more from a private water supply well**.tMe`thod used 6 determine distance "This system passe&if the welhwate`analysis,pet.rformed at a PEP cIt'vertified laboratory,for.coliform bacteria and volatile organic compoun8s;indicates.that thenwell is.free from pollution from that facility and the presence of ammoniaitrogen grid nitrate nitrogen is equail'to or less'than 5 ppm;'provided that no other failure criteria are triggered.A copy,ofct:lthe 1.analysis must be attached to this form. UC 1?t-it: is «(lnlu.:i,U. Cej_(,1 ;)($!.! � �...t:'t! 3. Other: ; `!: , . .,. ..... ...r. it i. . ' ,... ,. . ... I .. . .... t � , . -. 1!�i(?I� lt!'I;"i, :,tN; ,C u�S+�f'i-1C�' it;!t,•; ,;it" i1. I1iis u k ipn, t ati,ajuJ.,AS61 Page 4 of I 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART iA CERTIFICATION(continued) Property Address: #35 Ouaker Road Hyannis,MA Owner: James&Laura Ostanchuk Date of Inspection: 12/05/05 f D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or.system component due to overloaded or clogged SAS or cesspool XX Discharge or poriding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ` XX Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). 1,1111 Number of iimes pumped,., 1'lJ k A i <., ; c! c , CS; XX Any portion of the SAS,cesspobh or privy is below high ground water..elevation: XX Any portion of cesspool or privy'is within 100 feet of a surface water supply or tributary to a surface water supply. .1 ,1 ';''! XX Any portion of a'cesspool or pnvy is withm a Zone I of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX Any portion of'a cesspool or privy is less than 100 feet but greater than 50 feet from a private water siir hl ., i. supply well with;no-acceptable water-quality analysis. [This system passes if the well water analysis, performed at a DEP`certified labbratoiy;for'coliform bacteria and volatile organic compounds indicates that'tlle 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.] ,- , }u',.• 1i4 tl� NO (Yes/No)Ti` system faiis.cI ave determined that.one or more of the above failure criteria exist as described in 3l0 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. 1! E. Large Systems:,, , °i€ » ., To be considered a large system the syst�mmust serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria apply."to large systemsin addition to the criteria above) ; yes no the system is within 400 tfleet of a surface drinking�water supply; _ the•system is within 200 feet of a tributary to a surface drinking water supply • ,.tt,ft ,ri .ill•i4:,jk)�ii ('N.,�!'��}. •�G•,' . !' ,. _ the system is located in a nitrogen sensitive area(Interun Wellhead Protection Area—IWPA)or a mapped Zone II of apublic!water,supplyvYte�1 . ' If you have answered"y6"•to anyique$tionlin ection E the system is considered a significant threat,or answered "yes"in Section D aboyeahe la'rgesystem has failed The owner or operator of any large system considered a rl.!1.1 l , s f �.t.., r .})r s it .r,.; n , significant threat under.Section Et or failed under Section D shall;upgrade the syster i'in accordance with 310 CMR C..,,.,...,, 4 ' ,i i tSC'S4•Sl C'Iit !li':.�i:«�.:i:I�ti'iiC': %ii.:ai^ .., .'^� ;' fRC`! U; .... �. � ( r S I f$.. i ♦ .r Page 5 of 11 15.304.The system ownerr'should contact the appropriate regional office of the Department. 1 '0. -4 OFFICIAL INSPECTION:FORM NOT:FOR VOLUNTARY ASSESSMENTS SUBSURF ACE SEWAGE�DISPOSAV SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #35 Ouaker Road Hyannis,MA Owner: James&Laura Ostaychuk Date of Inspection: 12/05/05 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by°,the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period? XX Have large volumes of water been introduced to the system recently or as part of this inspection _ N/A Were as built plans,of the system pbtained and,examined?(If.they were not available note as N/A) 6 C., ,I'. fig' ;d�•CXr �.... r 41 I:ti XX _ Was the Tacility or dwellnig inspected fori signs of sewage backup? XX _ Was the site inspected for signs of break out'?`', "J';" XX _ Were all system:cpmponents;,excluding the SAS,located on site? XX _ Were the septic tank manholesl:ur}cov`ered,opened,-and the interior of the tank inspected for the condition of the baffles or tees,material of.,co,..nstruction,"dimensions;depth of liquid,depth of sludge and depth of scum? ,.. XX _ Was the facility`oivner(arid occupant Jf different from owner),provided with information on the proper maintenance of subsurface,sewage disposalsystew?=--- . The size and lockion of the Soil Absorption System(SAS)-on the'site`has been determined based on: Yes n0 dl'i? luttl� ci o1 t In till: i::C',I:L. ,^Pl XX _ Existing information:For example,'a plan,at the Board of Health. t -.,<l. 11U1'lli. :iU4\ i r XX _ 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)] tYi III >jJ`t:i;'( iI i t'2Gi< ' 71 ..,. �11Iillltt,ycl. t\ .!(j1. . h.,. .. taJih'Ul.tll{IUi�€;(:��'kl'Ct�l ,?:lil It. .ii,� il'I ' I;lt 1 C t: C',lj..t it i Cc 01 t-" At Page 6ofII 's 64 i Y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :PART: SYSTEM'INFORMATION Property Address: #35 Ouaker Road Hyannis,MA Owner: James&Laura Ostanchuk Date of Inspection: 12/05/05 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 5 Does residence have a garbage grinder(yes or no): - No Is laundry on a separate sewage system(yes o'r no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 109,000 gallons—2003/114,000 gallons 2004 Sump pump(yes or no): No I Last date of occupancy: Currently oecupied COMMERCIAL/INDUSTRIAL !'v) Type of establishment: �. :,f;{ {,'l;�. s Design flow(based on 310 CMR 15.203):, i%`j 'T,-"Wd� Basis of design flow(seats/persons/sgft,et'..), ' `i. '� <i 13 s , '>`►s �.' Grease trap present(yes or no): Industrial waste holding tanl�present(yes for no): Non-sanitary waste discharged toDthe.Title 5.sy`stem-(yes or-no): Water meter readings,if available:-'=- -- — il , . ... ... .. t___...- ---Last date of occupancy/use: --- _._ E OTHER(describe): GE N cAL INFO�cRMATIONI; Pumping Records Source of information':"! - Was system pumped as parf of the inspection(yes`or no):NO If yes,volume pumped `±` gallons ;,Hove was-quantity.pumped determined?, Reason for pumping: TYPE OF SYSTEM } XX Septic tank,distribution b'ox,soil-absorption"system Single cesspool _Overflow cesspool Privy Shared system(yes or no)(if yes,vtach previous inspection records,if any) _Innovative/Alternative technolody .Attach-a copy of the current operation and maintenance contract(to be r,1 . i�ra\!IC r ..- .).w-r�Jl•,i a!$_:�.. .:.. . ._ 'l obtained from system owner) - �� ...,. _Tight tank Attach;a copy of the DEP approval h, op -.ty Other(describe): Approximate age'of all components;date installed(if known)and source of information: Overflow leach ait installed in 1995,= per Owner&BOH Records .4 Were sewage odors detected when arriving at;the site*(yes'or no): No--==- , P 7 T d 2 k .1 - T ., � . 6' Page 7 of 11 sa a OFFICIAL INSPECTION FORM,—NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ..,.,. PART C ` SYSTE INFORMATION(continued) Property Address: #35 Ouaker Road Hyannis,MA Owner: James&Laura Ostapchuk Date of Inspection: 12/05/05 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction: cast iron �40 PVC XX other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): a d� SEPTIC TANK: XX (locate on site plan) Depth below grade: 5 feet to Top of Tank i Material of construction:° XX i concrete t',metal `fiberglass r; polyethylene� y a _other(explain) J' :t ! I (1�'`,yl:�'1.4a ,{i :,5�• \ li Y r, I If tank is metal list age:_ 'Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) i�ri''' i a l3? try s'it3', is"r Dimensions: 5' deep x 5'wide by 8' lonz (1,000 gallons) Sludge depth: 4.0' Distance from top of sludge;to-bottom-of-outlet-tee-or baffle:,-2' Scum thickness: --2 'inch scum-laver-noted---- -- Distance from top of scum to,rop`(of outl'et-te'e or:baffle:—8 --- Distance from bottom of scum to-bottom-of outlet tee or baffle: 17" How were dimensions determined: = rw.r -'.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.): Structural integrity of tank was ok:No evidence of cracks,leaks,or water infiltration/eAltration Concrete baffle present at inlet end. Outlet Baffle present and in'aood condition�Liquid level equal with outlet invert. .. ,!. ". ,. . � -I),.Ii;,, ii,iitif_ °�'.\'ICi�liC4 l.. IC•t ,t .. - GREASE TRAP:_(locate on site plan),-,"' Depth below grade:,.,L (lt C,lIc:•"ii ut�`hi ' )j Material of construction: concrete -it metal fiberglass_polyethylene_other (explain): Dimensions: 's X cool"i do, Scum thickness: Distance from top'of scum to top:of outletlee-or.baflle: "• tn! Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: r_ t__�,it+v_,rc Comments(on pumping'recommendations,inlet and'outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert;evidence'of leakage;etc:)�l•`',!i.l • � 1 •,:..'lof!sC` t t��rttl. I�EL',airra.'et. • K. a- " t)i �iit it tO•tJil;[y;•!! ( =,:.i1'.Y:l . .,sf.`."�„c .i- - �: -�----- >t' Cw., it., - .. L m•n r. r. i!}jr/ ^,'i���a�P_1CF Ua t:�l.i y c 7T�_ - x>'.:' , tii l:. ate.c__i?(, Page 8 of 11 OFFICIAL INSPECTION FORM'—"NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART,C s SYSTTIV INFORMATION:(continued) } Property Address: #35 Ouaker Road Hyannis.MA . Owner: James&Laura Ostavchuk Date of Inspection: 12/05/05 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 i Design Flow: gallons/day,, Alarm present(yes or no): 't. ' 4 Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float,swttches,,etc.): S 1 i';tv: i t1'< id.:1..i DISTRIBUTION BOX: ;. (if present must be opened)(locate on site plan) Depth of liquid level above outlet`invert-' -- Comments(note if box is level and'distnbutioirto outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,-etc:):- 'NotFound-or-present-�:_ PUMP CHAMBER: (locate on site plan), ' Pumps in working order(yes'or no): Alarms in working order(yes-or no)? `il""I `- t Comments(note condition of pump-chamber`;condition of pumps and appurtenances etc.): ;,I'll ni :+nt{ � yjt l VA _ )\ , i�\t', ;IiiGl.L11Jti'IC)UC1Vil .,..vIIiIC:� ..�!G :'I;; ..iLi:i. ', . . .• , I k "I. - I •.,l.i. - p Page 9 of 11 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM .PART C ' SYSTEMINZ'~ORMATION(continued) }` Property Address: #35 Ouaker Road Hyannis,MA Owner: James&Laura Ostapchuk Date of Inspection: 12/05/05 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type XX leaching pits,number: 2 leaching chambers,number: leaching galleries,-'_mlier: ` :0 01`'N_ . 1 '.1; leaching trenches;number`,length-.,. 9 F leaching fields,number,dimensions: overflow cesspool,,number: innovative/alternative system"Type/iiame of technology: Comments (note condition.of soil, signsaof hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hvdraulic failure-of septic tank or of leach pit#2 Leach pit#1 has been hydraulically failed before. New pit installed in"1995.,Tof of-leach-pit is 5' below ground Riser present on both pits 4' effective depth available CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: t', „" '' ";,. Depth—top of liquid to-inlet;invert:,, t r,� x.,it -� .. ,.T+il{' t,Ll il.�t` C,,V..i. ,..•. ,. Depth of solids layer. Depth of scum layer: , Dimensions of cesspool:" Materials of construction: Indication of groundwater inflow-(yes-or no):�' Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site' Materials of construction. Dimensions: , Depth of solids: " " uil.,•<<,c 75! 1 I •c,li,. ,,!; r' !ev�� t i i;;r,• ,c , Comments(note condition of­'soil;signs of hydraulic failure,level'of pondin It g,condition of vegetation,etc.): T>y V' "1 1.f1 Ali',(i�nn`i is `X• ` •"a9- ,i 'J fn♦ 7 Page 10 of 11 —.—._.-_:. _.^.-__ r L.nt�`ry'.'.y._,_� -!vim__._�•_ ,_.�.._._`_,_�--.-. , :f OFFICIAL INSPECTIONFORM—,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM TART C i "' Y SYSTEIVI INFORMATION(continued] Property Address: #35 Ouaker Road Hyannis,MA Owner:_ James&Laura Ostapchuk Date of Inspection: 12/05/05 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. Swing Ties: QUAKER ROAD, - 1 A- Tank In—21' B- Tank In—23' A—D-Box—32.5" B—D-Box—21.5 A—Leach Pit#1 -54' Water;Line;• B—Leach Pit #1-28.5' A—Leach Pit #2—28' v B—Leach Pit #2-30' t. 4. 1Z •5 /)- • " 1 _ _ __ _. _fsir_�e�,��{.a; `c_(�tit�+;+• Lilt___._._ Exist House ;• ,. t , A ; .,J!IJ\1ti113} InoIk I,.! B ,,Peck i Septic Tank (1000 Gal.) R `ws Li s'k.•' D-Box --0 Leach Pit#1 0 ;Leacf. 1 h'Pit#2 ! 10 Page 11 of 11'„ t �,u,� U� ;e� t� ��t at(Iojuvai J I;U art ;W ,�,: :h , r �'r,E tt t t:: ^!,. . .. s ., t ;t.c=' OFFICIAL•INSPECTION,FORM--�N.O..T,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWA�GEDISPOSAL SYSTEM INSPECTION FORM A.y'. 7a PART C 'SYSTEM INFORMATION(continued) Property Address: #35 Ouaker Road Hyannis,MA Owner: James&Laura Ostapchuk Date of Inspection: 12/05/05 SITE EXAM Slope Surface water -'/2 mile+/- Check cellar -Yes Shallow wells-None Estimated depth to ground water 20' feet 'k` Please indicate(check)all methods used to determine,.the high ground water elevation: :.s Obtained from system design plans on record'-If checked,date of design plan reviewed: XX Observed site(abutting property/observation hole within 150 feet of SAS)i. Checked-with local+Board'-of Health-explain: Checked with local exca'vators;'instaUe s#!(attach documentation),'," F " ; XX Accessed USGS database-explain: t , • Fw,I You must describe how you�establishedithe high'ground water elevation: Checked with Ouadranale ofUSGS Mangy T--" '- Per USGS MAP PLATE 2: Elev.of Ground=49 Feet Elev.Of Groundwater=20,Feet Elev.Of Bottom of Leach-Pit 38 Feet Therefore: 38-26= 18 feet separation.between Bottom of Leach Pit and Groundwater. Groundwater Adjustment usmgInd&Well MIW29(C): 3.2 feet Adjusted Groundwater Separation= 18'-3.2-14.8l:feet between`bottom of pit and adi,groundwater t ,, .,. .,. a in t u,c• s , a,s'�/ �...t..,.-u u. �-r,�:.t.;,,uu� Grade=Elev.49 feet H} t, t S011 il:-ift�l P�lllEG�llla, ' 1 1:^ 1: t Septic Tank t �IBottom of Pit=Elev.38 feet - -- Adj.Groundwater=Elev.23.2 1 i i '_� :Ift{ f..t.�i ti r li ' Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: BUSINESS LOCATION: MAILINGADDRESS: r-Np_ Mail To: Board of Health TELEPHONE NUMBER:Q t5b-K) Town of Barnstable CONTACTPERSON.; _ .5{� e.S ' C�� ,���,J� P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: {2 d"r�'w�.heM CSbtHyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: 'LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant.systems) Drain cleaners NEW --USED Cesspool cleaners Automatic transmission fluid Disinfectants 1 Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer), lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, { NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners . (including chloroform, formaildehyde, 1 Floor& furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not,listed which you feel may be toxic or hazardous (please list): r' (including bleach) Ff� Spot removers & cleaning fluids (dry cleaners) - v Other cleaning solvents , Bug and tar removers - " I WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN OF BARNSTABLE LOCATION aS 6�QA- /L C SEWAGE VILLAGE�N LA ASSESSOR'S MAP & LOT -7/0 —,704 INSTALLER'S NAME & PHONE NO. �v `— 69 /Qd 4 SEPTIC TANK TANK CAPACITY LEACHING FACILITY:(type) /`�iT' ) (size) 6 p4-Id3 NO. OF BEDROOMS PRIVATE WELL C-WAS BUILDER O O a DATE PERMIT ISSUED: ��-�9� DATE COMPLIANCE ISSUED• == ' = VARIANCE GRANTED: Yes No rN zj C 1- r w ` FEB.....70...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Diinpa!ml Works Tatuitrnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair (b< an Individual Sewage Disposal System at: ,7-5— �( vA-► /--nrr--�J' --------------------------------------------------------------- .............................. ........................ Location-!\ddress or Lot No. Owner 7 4 — A dress alcSi-Qt.�r.� �fr,1- G�11�-1L�1� �l�f, /t�l ---- ---------------------- - Installer ddress UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms..............,7. ------------------ -___Expansion Attic ( ) Garbage Grinder AjO aOther—Type of Building ---------------------------- No. of persons._-_-__._--_.-..-__--_.--_- Showers ( ) — Cafeteria ( ) dOther fix es --------------------------------------------------.__.-------------------------------- ------------------------ --------------------------------- W Design Flow...............:.............._........_.._.gallons per person per day. Total daily flow----------------:7- 0 ..........gallons. W Septic Tank—Liquid capacity/ Q__gallons Length________________ Width______-_._-..__ Diameter---.---------._. Depth_..-________._.. x Disposal Trench—No. .................... Width_..._.....__._______ Total Length_._______..-y__--_- Total leaching area....................sq. ft. o I Seepage Pit No-------/.......... Diameter-____. ----- Depth below inlet______ ___________ Total leaching area..................sq. ft. Z Other Distribution box (P>4-. Dosing tank ( ) Percolation Test Results Performed by----------------------------••------------------------••---•------------. Date........................................ Test Pit 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_.---._.___--__--______- P4 ------------------ ----------•------------------•--------•-------------•-•---•-------------••--•---•......................................................... 0 Description of Soil........................................................................................................................................................................ x w -------------- --------------------------------------------------------------------------------- ------------------- ----------•-------------.....------. --- ------ -•---------------... U Nature of Repairs or Alterations—Answer when applicable._.___._--✓---..___- ......... ------pf = ---------- ----------w.-----------�------------z--.►----------- -...... Agreement: -L- 7 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 Compiian as een issue b e board of health. Signed ---- ---------------- IF, Da�e Application.Approved B � ------ - Vt_'"e .:.. LDace Application Disapproved for the following reasons: - ------------------------------ ----------------------------------------------------------------------------------....------------......__---_..... _......---.--.---- ---- ---------------------------------------------- ........................................ Permit No. .. �"�'............... Issued .. _G.........-.. -.... ..; ......... Dace No. _. d Fms.....-`..Q..�..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABL.E Appliration for Mit-p ml Nor1w C owitrttrtion Veratit Application is hereby made for a Permit to Construct ( ) or Repair (N� an Individual Sewage Disposal System : 3-5— �j( v e �i�-,-,-JrV is ..-•---•-••---..-...--•................•--...G.....---...._-•••--•--•--•-••-•-------••---_------ •-••••-------•••---••••-•-••-•-•----•------•------•-•--------•----------------•.....-....-----__._ �-- Location-:\ddress "r Lot No. ................................�l 1 �5— ----�..J✓a-K�1'�-•-------••---r=---..-..... r�.. --------_--- Owner Address Installer 'Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms--------------3_-__--------_--.-.--.- Expansion Attic ( ) Garbage Grinder (—) NV p` 4 Other—Type of Building -----.-----_------- ------ No. of persons-_------_---.-----------_-. Showers ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------- ---------------------------- Design Flow............... .........................gallons per person per day. Total daily flow.......................... !.'__-........gallons. WSeptic Tank—Liquid:capacitvAP a.-gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length----..--.-_-_....... Total leaching area....................sq. ft. AV.—Seepage Pit No-------/---------- Diameter....../ -.-- Depth below inlet------6-.......... Total leaching area..................sq. ft. Z Other Distribution box (,L)_ _ Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date...................................... Test Pit No. 1----------------minutes per inch Deptll of Test Pit------------........ Depth to ground water--.---_--..-.--..---_ fs. Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water........................ a --•-------••-----------------------••-•-••---------------••-----•--•---•-•-•-•----••----•-..........•----••--............................................... 0 Description of Soil.............................. _=-------------------------------••---------------------------------------------------------------------------•-•---•----.......---••--- x --------------------------------------------------------------------------------- -_--------------------------------------------------------------------------------------`.......................... U Nature of Repairs or Alterations—Answer when applicable..-..�'D----_-'4---------1000___��,�__.-____C-_ ....-tom}__•___. �� J -=-........------. "...... 'T -•-----S 'Z...►....--------'-...--- ...'------....x-f-..:i!.^..... Agreement: - --5-X5 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issued by e board of health. Signed ......,i. .... _...... ce _ Application.Approved B - - ...._.. _... �2 1 ......... .. ......... . .... - _ ; - ��'� Dace Application Disapproved for the following reasons: -------..._......... ... ... - - - = - ---------------- - -- -- ------...------------------------------------------------------------ ------------......_......---_--------....._-------------------------------------- -......---------------_--------------- Da— Permit No. ......_. -- '' .. --------------- Issued ._v................... ...'... �' 1e..... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (?C) b ------------------------- .....-.. .......... ��G. .-tom'-Z----------------- ------------------------------ - �L f `..�at ..................................................... 3 ------------- -- .. 7 ----------- -----------............._ has been installed in accordance with the provisions of TITI. 5 of The State Env ironmental de as described°i the application for Disposal Works Construction Permit No. ._. dared- ...__'"..�' THE ISSUANCE OF THIS CERTIFICATE SHALL N T n CONSTRUED AS A GUARANTEE_THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....-�,� � .. � � . ...... Inspect .. THE COMMONWEALTH OF MASSACHUSETTS� _ T y�`✓ / !��� BOARD OF HEALTH �C TOWN OF BARNSTABLE No................. ..... )''EE........---............. ej Permission is hereby granted--------- ----�G✓L-I .. c,u. 7.-------------�'=`.1.5 ...........�.......................................... to Construct ( ) or Repair ( „ an Individual Sewage Disposal System atNo............................................ � T.t _ ..£.�..,..__.l- 1 ------ ----- �'�� - Street/��__:/i� .'_"7�---J - as shown on the application for Disposal Works Construction: '�it {hw�ilo �_i ateds.��_______ _._..._. ---- Board of Health DATE---------------------- ....................=....................... FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS