HomeMy WebLinkAbout0035 SEABROOK ROAD - Health f 35'Seabrook.:Roacf
-Hyannis P
A307 "011
0
I�
No. go. 3 ~ b 73 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
I Applitation for MisposaY 6pstrm Construction 3permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon 70 Complete System ❑Individual Components
Lo ation Address.or Lot No. 3 se�� Owner's Name,Address,and Tel.No. c .J7��
A� sos I�fa jJarceI PO" /a'J 1,1 LS '' l C d CJ 5/A 5l / J
Installer's Name,Address,and Tel.No. pe) Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) A/ 4— _ gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank T e of S.A.S.
Description of Soil
Nature o epai or Alterations(Answ r when applicable)
✓'
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board a h. /
Signed ( Date
Application Approved by Date 3 Application Disapproved Disapproved by Date
for the following reasons
2oi3 r 3
Permit No. 0 Date Issued 3 — LI-r
�� J Fee
e
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Vsposal *pstrm C0 tCUction �rrmit
Application for a Permit to Construct( ) Repair( ) 'Upgrade( ) Abandon ❑Complete System ❑Individual Components
Location Address or Lot No. 3 5 S� C Owner's Name,Address,and Tel.No.
As�sgs 1VPaplarcel /v
Installer's Name,Address,and Tel.No. PU "go>( 77s Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) A/ �— gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil rr fir
Nature o epai or Alterations(Answer when applicable)IV It IAI 70
Date last inspected: 3f`��21(,743
,t r
Agreement: _
z The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of "-~
Compliance has been issued by this Boardr� aoh.
Signed _ Date q&015 ,t
r Application Approved by Date 3 c/—j?
Appli ation Disapproved by Date.
for the,following reasons
Permit No.
D 1 3 073 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS O CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( by FIB rn CD/1TYu1��f"Z57UJ
at S E_,A i� (2,9 ^( Was been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Noa D 13-0�3 dated 3 i"(^ /3
Installer PILM CO tJ--rM CT2)FW ((1 C Designer- N
. _„ � /
#bedrooms Yv - Approved design flow /+- A gpd
The issuance of th• a it shall no be construed as a guarantee that the system 11 fu\nc •o as de 'gned.
Date InspectorX/�Mwk
T
--------- -------
-
No.a 6 ) Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
30isiposal 6pstem ConBtCULtion permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(
System located at r 1_ 5 I( )(�� L U2 t I j n n p 1 ;�- O U0 0 ,I
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permi4.---,-_ I
Date �j ' 14- / Approved by c
�.
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date 5 (2-012— Time: In Out
Owner C®p�S' A ku Ac UO-S' SW Tenant
Address 5bSIA TA E- Avg Address
Poa:�- FL tj i Ira- ,
Compliance Remarks or
Regulation# Yes I NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply t/ `
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural J
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17. Temporary Housing
18. Driveway Width io
19. Number of Tenants Observed Z
PART 11
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehicles Allowed
Number of Persons Allowed (max)
Person(s) Interviewed CITiy ( � Inspector'
utiyl
If Public Building such as Store or Hotel/Motel specify here
UNITED STATES-POSTALSERVIGE ,First=Cl'ass',Mail .`....
y._ .. 2th9 $ eec pa d
• Sender: Please print your name, address, and ZIP+4 in this box • „
"tr�Nk Town of Barnstable
. .�s):
y.Jt Health Division
J _00 Main Street
Hyannis, Mk 02601
}
i
! 14„11,,,,,,1111till It lilt ,,,i1lll is Ills,,,l,l,l i
p—
I
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
--------------
■ Complete items 1,2,and 3.Also complete A. St ature
item 4 if j Restricted Delivery is desired. ❑Agent■ Print your name attd address on the reverse X Addressee
fso that we darr'return the card to you. B. Received y(Printed me) C. Rate of liv
■ Attach this card fo the back of the maiipiece, ) 5 271
or on the front if space permits. I
D. Is slivery address different from item 17 Yes
1. Article Addressed t
If YES,enter delivery address below: ❑No
Constance McCrossin f✓A Q N
5634 Taylor Avenue 3. Service Type
Port Orange, FL 32127 4ACertified Mail ❑Express Mall
t3 Ri gistered MZtetum Receipt for Merchandise
- - ❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. .Micle Number
(transfer horn service label) 7 0 0 8 ' 3-2 3 0 0002 517 8 0325
l V
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
f
Certified Mail#7008 3230 0002 5178 0325
tad, Town of Barnstable
Regulatory Services
MARKS BM
MASS. $ Thomas F. Geiler,Director
Public Health Division
Thomas McKean,,Director
200 Main Street, Hyannis,-MA 02601
Office: 508-862-4644 Fax: 508-790-6304
May 20, 2011
Constance McCrossm ��o
5634 Taylor Avenue ( 1
Port Orange, FL 32127
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II —MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 35 Seabrook Road, Hyannis was inspected '
on May 5, 2011 by Timothy B. O'Connell, R.S., Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of the rental registration in
accordance with Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed: 1
105 CMR 410.351 - Owner's Installation and Maintenance Responsibilities.
Front left burner not working on stove.
105 CMR 410.500- Owner's Responsibility to Maintain Structural Elements. Garage
door windows are broken.
105 CMR 410.482—Smoke Detectors. Smoke detectors not present within basement.
105 CMR 410.480-Locks. Garage door does not lock. 1/0,
You are directed to correct the violations listed above within twenty-four(24) hours
of your receipt of this notice by installing smoke detector within basement; by
ensuring that garage door locks. You are directed to correct the violations listed
above within-thirty (30) days of your receipt of this notice by fixing or replacing
above mentioned burner.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten(10) days after the date the order is served.
QAOrder IetterMousing violations\35 seabrook 5-23-1 Ldoc
. 7
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF T BOARD OF HEALTH
�a
kI.ean, R.S., C
Director of Public Health
Town of Barnstable
Q:\Order letters\Housing violations\35 Seabrook 5-23-1 Ldoc
f ,
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date `2 vZ0 P Time: In Out
Owner 6204A-�- Tenant
Address (o A"� Address
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply 0 . 4
5. Hot Water Facilities -�
6. Heating Facilities
7. Lighting and Electrical Facilities �� ►.►wry
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural �` 4- ��
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17. Temporary Housing 12c)
18. Driveway Width £2�
19. Number of Tenants Observed
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehicles Allowed (max)
Number of Persons Allowed (max) 5 --t---
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
�.
,
F,,a^6AM30 CIW HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
�. BOAPEP OF EA LTH
Q� Fob
CIT /TOWN
W ,
D PARTMENT
o1 '
i
AD
LEPHONE
Addres IC,j _ Occupant V'0 j ,r
Floor Apartment o. No.of Occu is t�/✓
No.of Habitable Rooms No.Sleeping Rooms
No.dwelling or rooming units 4 N_ . tori
Name and address of owner
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish ,
Containers: Ato Viol
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 11220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: I
Stacks, FI es,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 INSP CTOR.(See Over)
"THIS IN PEC N P RT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENAL O P "
INSPECTO TITLE _
A.M.
DATE 0 TIME C
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
rM, S
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. Fa lure 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(3)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 quanti':y, 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 410.231 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 of covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of po%dered, 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.
COMMONWEALTH OF MASSACHUSETTS ! 13 3 3
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
> DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP 07
PMCEI.
LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORT I
PART A
CERTIFICATION
Property Address: ,
Owner's Name: �fe c 2 !r / R�(�,E:'�E:®
Owner's Address: .3'" S�� �,<�o l„ p
v 6 z- 1 2003
Date of Inspection:
Name of Inspector. (please print) / /w — �5v/� ' N OF BARNSTABLE
Company Name: Z--1Wi p �- -�� TOWHEALTH DEPT.
Mailing Address: G'�G�e ,! �
C".r-I-ti o,v0 rE oZ
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Ption 15.340 of Title 5 (310 CIVIR 15.000). The system:
"asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F
Inspector's Signature: = %�t.�l ' Date: 7 (7
The system inspector shall submit a copy of this inspection report to the ApprM ing 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.
Notes and Comments ,
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
rage 1 of t 1
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection: �i��
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A_ Sys m Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CNIR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. �Sysstem Conditionally Passes:
/� Cnte or more system components as described in the"Conditional Piss"section need to
or
re red.The stem upon completion of the replacement or re be replaced
� system, � pair,as approved. 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
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«ill pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water IL%-el in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipc(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
rar,c J vL A.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: �� �v�/t�if�U`✓ Ad
Owner: C/rh k? f'1
Date of Inspection: c'3
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.
I. System will pass unless Board of Health determines in accordance with 310 CINTR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or pricy is within 50 feet of a surface water
_ Cesspool or pricy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any) 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 1o0 feet of a
surface water supply or tributary to a surface water suppy.
The system has a septic tank and SAS and the SAS is*within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other.
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
�n: ,>
Owner• C1Date of Inspe p
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no" to each of the following for all inspections:
Yes k
Backup of sewage into facility or system coriponent 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
�O tatic liquid level in the distribution box above outlet invert due to an overloaded or clo ad SA ggS or
esspool
rrr���//////___ squid depth in cesspool is less than 6"below invert or available volume is less thatt�/:day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
Of times pumped
_ /Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface Wtiter supply or tributary to a surface
_ X/water supply.
,Any portion of a cesspool or privy is within a Zone 1 of a public well.
y 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,
F;rforr.c--' DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates U.". :ne 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
arc triOecred.A copy of the analysis must be attached to this form.]
(Yes/No)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 s-ftem the System must serve a facility with a design flow of l0,11+)4 gpd to 15,Ot)U
gpd-
You must indicate either"yes"or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— _ the system is within 400 feet of a surface drinking water supply
_ the system is within 200 fe--E 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 1---?,e 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 CbtR
15.304.The system owner should contact the appropriate regional office of the Department.
cage 5 Ot 1 l
efi ,
OFFICIAL INSPECTION FORNI NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: ���cc„//
Date of inspection: '7/p-7
Check if the following have been done. You must indicate`des" or"no"as to each of the following:
Y�No
Pumpin information was provided by the owner, occupant,or Board of Health
/ oWere
anv of the system components pumped out in the previous two weeks
the system received normal flows in the previous two— p o 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 sevvage back up
!/ Was the site inspected for signs of break out
v Were all system components,excluding the SAS, located on site
Were the septic tank manholes uncovered.opened, and the interior of the tank'
ffles or tees, material of construction,dimensions,depth of liquid, Inspected for the condition
of the ba
/ quid,depth of sludge and depth of scum
_✓_ Was the facility owner(and occupants if different from owner)provided Rich information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes n0
Existing information. For example,a plan at the Board of Health
ZI-L Determined in the field(if any of the failure criteria related to Part C is at issue approximation of di
is unacceptable) (310 CNIR 15.302(3)(b)j Pp stance
gage o or t t
J OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM L 1SPECTION FORM
PART C
SYSTENI INFORINUTION
Property Address: k,
Owner-
Date of Inspection: ,E -2 G>
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CAR 15.203 (for example: 110 gpd x#of bedrooms): 3-7o
Number of current residents: j
Does residence have a garbage grinder(yes or no) S
Is laundry on a separate sewage system ves or no .—^if Yes separate to inspection
on required]
1
Laundry system inspected(yes or no): A/'
Seasonal use: (yes or no):,,,±�
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):tip'
Last date of occupancy:
CO NMERCIAIJIND USTRIAL
Type of establishment: .. ,
Design flow(based on 310 CAR 15.203): zpd
Basis of design flow(seats/persons/sgfl,etc.):
Grease trap present(yes or no):_ ,
Industrial waste holding tank present wes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of oc.^lpancy/use:
OTHER t. x):
GENERAL LNFORNIATION
Pumping Records
Source of information: `4+ ���f _ t�C)i — p t,.,v�e
Was system pumped as part of the inspection(yes or no): X'V
If yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping:
TYP"F SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no) (if yes, attach previous inspection records, if anv)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)-
_Tight tank' _ _Attach a copy of the DEP approval
_Other(describe):
Approxdmnte age of all components,date installed(if known)and
so� e of information:
Were sewage odors detected when arriving at'he site(yes or no): /��/
Page 7 of I I
y '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: S =f i S'uc,/' /�j
1 N.,,s G e;cy
owner: Cry
Date of Inspection: y
BUILDING SEWER(locate on site plan)
Depth below grade: /T
Ntaterials of construction: _cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:L(locate on siteplan)
Depth below grade: 5 r
Material of construction: &,concrete metal fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate
certificate) of Compliance(yes or no):_(attach a copy of
Dimensions: , X
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3/
:Scum thickness: /
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to botto�,of outlet t or baffle:
How were dimensions determined: 761le 1 C e
Comments(on pumping recommendations, inlet and utlet tee or baffle condition, structural integrity, liquid levels
as rated to outlet invert,evidence of.leakage,etc.):
f !� ,p F3 ,- i .-. � r i ctii(�• G;v7/r GP H� k���7 �c-S
c G
GREASE TRAP;/ (locate on site plan)
Depth below grade:
Material of construction:_concrete metal fiberglass
(explain): _ _polyethylene other
_
Dimensions:
Scum thickness:
Distance from top Of top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: e
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structur as related to outlet invert,evidence of leakage,etc.): alintegrity, liquid levels
Page 3oCli
• . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner. Clcr�Y
Date of Inspection:
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:
Design Flow: gallons
galIons/day
Alarm present(yes or no):
Alarm level: Alarm in workingorder
Date of last P Pum in (yes or no):
Comments(condition of alarm and float switches, etc.):
DISTRIBLi,0% Ems`:_
__. . (if present must be opened)(locate on site plan)
Depth of liquid level abov,: invert ( ���
Comments (note if box is 1c•,cl distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc,): /
Itlo
a
PUMP CHANMER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances.etc.):
Page 9ofII
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM UFORMATION(continued)
Property Address: �� > i�0 f��f
Owner- �__"
Date of Iection: 6 C2
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
TyJL
leaching pits,number. X
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,datinp soil,condition of vegetation,
etc.) J ,
U rG N C.
CESSPOOLS:J�(cesspool must be pumped as part of inspection)(locate on site plait)
Number and configuration:
Depth—top of liquid to inlet invert: .
Depot 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:Zoocate on site plan)
Materials of construction:
Dimensions:
Depth of solids: .
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
a.a�.. •.. ..• •.
� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
t Property Address: h/
Owner. 4L/-
Date of Inspection -
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.
a
�i r-;,3 '
Page 11 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORIN ATION (continued)
Property Address- � a
77;
Owner.
Date of Inspection: C '
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater feet
Please indicate(check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
rved 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: .,
J OF You must des how you estatished th 6h gro�nd waterglevahoo:
C.
To
—�, llcpa �_'
O }`s1
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME & ADDRESS
D
G U I L D E R OR OWNER
DATE PERMIT ISSUED q-��'7_ �
DATE COMPLIANCE ISSUED
}
M� d
� N
4
No, FEE............ ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....-- ...-- .....................OF.............. .........._......._...
Aptiration for Disposal Works Tonotrurtion Frruat
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
......... .....:...:....................••---••-•-••-•--•--------•----•-... --------------------------------------------------•----------------------------------------
Location-Address or Lot No.
Owner Address
7/
Installer
� Address
Type of Building - Size Lot___________________________Sq. feet
.—I Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of ersons__________________ __ Showers —
a YP g -------_•_-----------•--•--- P •------- ( ) Cafeteria ( )
POther fixtures -----------------------------------------•------------.••••----------...-----•-----•-------••-•---------•-•-.........................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid'capacity___.__::____gallons Length................ Width................ Diameter—............. Depth................
W Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total,leaching area....................sq. ft.
�: Seepage Pit No--------------------- Diameter.........._......... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ------------••---•-------•; ..........................................................
O Description of Soil-------------------------/00 t--:/c�� /,! ',3 J� /000
x •••-----•--_---- ••--•---•-----•-
V .......................••-••..................•----.....-••-•--•--.._..--•-•...--••------•----•----•----••--•--------•-•--••----•-•-•-----------•--------•---•--••---••...--------------•-•-------------
W
V Nature of Repairs or Alterations—Answer when applicable.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
Signed z 7
----------- ................................ ._
r Date
Approved B --------
PP Y - "�------------------------------------
Application
ate
Application Disapproved for the following reasons-......................................................................................................:........
•-------•-•---------------------------------------•-----•--•-------------•---•--•---------•-•-----------••-------------------------------••-----••------------•----••---------•---------------...._..._
Date
PermitNo........................................................... Issued-...................................................
Date �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
C9rdifi.ratr of Tontplianrr ` k
THIS IS TOXERTI FY That the Individual Sewage Disposal System constructed ( ) or Repaired
by.. , T= -•-------------------------------•--•---- --•-•- -------------•-------•--..._......._....._---------_..... ••--•-• -•----•-- .
�. Installer Z
'
has been installed in accordance with the provisions oVTITI,.7 5 of Th.e State Sanitary Code as described in the
application for Disposal Works Construction Permit'No------_:___ �"__. 1� <__ _...... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIONS ISFACTORY.
DATE................................................................................ Inspector.........- =-��''
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
GfP ........................OF.....................................................................................
No... FEE........................
Disposal o ko onqtr iolt rrtni#
Permission is hereby granted----------------•--._..: ..'....: - l ........................................... ••-•---------...........................
to Construct ( )• =.Repair ( ) a dividual Sewage Disposal System h
f� .
Street
as shown on the application for Disposal Works Construction Permit No-------_--_---- Dated.........•.................................
oard of Health
DATE............................... •- 7=---:..-•---��-- --•-------•--•----
FORM 1255 A. M. SULKIN, INC., BOSTON -
�LI
No................�....... Fss............ ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
------...... .....................OF..........................._.......... .--------.............--------..........._.......
Appliraiion for UiipooaI- Varkii Tonotrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.. •••_..... ...-•--------•--•-•-•-•..............•--•---•-•-----•-•-._...-•---------•------•-..............--
Location-Address or Lot No.
...... ��YNl f................................................./ ..._C04..9...---..............------•-----.._..... ------------------------•-----------------------
Owner ..........................•-•-Address
a ---•-•• .... _...... !Y ............................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa Other—Type of Building. ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures -__•_-•--__--•--------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-____-_•_---_______sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by...........................................................
•---------------- Date........................................
Test Pit No. 1...........:....minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----_______-____--_____-
-------------------------�••••••---•-••••--•-•••--------•----•-••--------•-----•-a-------•------•----------•--•------------•-••---•---•--------------
O Description of Soil.........................A00.D_.../-- Il/ .......6 4.4.....----100g..ke
x
W ----••-•---•---- -----------------•----•-•-••--••-•-----------•-•--••--••-••---•----•---•-••----•-••-----------------•------------•----•----•------•-•-•••••----••-•-•-----•-•--------•-•----•-•---_....
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
--- ---------------•---------------------•--------------------........_..............................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'=- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued by the board of health.
Signed........
//D•�ate
Application Approved B .................•-- ~'a..�'--..L_,� �j
rr rr y -
Date
Application Disapproved for the following reasons:................................................................................................................
-•-----•---------•---------------------------------------------•------•--•------•------------------------•----•-••-•-••--•---•----=---•---•---------••--••-----•-•---••-••-•--•----•--................
Date
Permit No..----•............. •--•--- Issued_---------------------------
_ ....--------•--------------•- Date ------•--------^-•-------.