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HomeMy WebLinkAbout0064 SEABROOK ROAD - Health 64 - 68 SEABROOK RD.: HYANNIS A = 307 017 ti l �I 3 .: t • s °h Town of Barnstable opanVIiENp BARN ABLH. I • SI' ' Public Health Division f U.S.POSTAGE>>PITNEY BOWESain Street 16 MAR � r 200 M � +�p1¶ MA55. �f'L.A. A O arm jEc rna+ Hyan nis,MA 02601 4;1 ZIP 02601 11I - 02 4VV $ 006.960 7015 1730 0001 4987 8593 i 0000373143MAR 16. 2021. ,I c•� �--� c h-4=, 1 C� HFTi3RN Tfl ss.FNn.FR 1 i UNCLlAIMED � aIi3ABLE TO FORWARD C4 0 r.e � Yd .:L..T 3 1 F:D -193&a111.1sI1ltllai9l111:11`11ia1ra17iaaa`11. 1111i1atati111i 1111: —11 �a e 1 a :d-H l r \_;„ .y,� .ty , y ., :� ,fifr�� • 1 • • ..fib � �.J .• !i 1XWW ® Complete Items 1,2,and 3. A. Signature l to Print your name and address on the reverse X ❑Agent so that we can return the card to you. ❑Addressee l a Attach this card to the back of the mailpiece; B. Received by(Printed Name) C. Date of Delivery or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑ No �-z�-Fi Mom• �-4� � � I i I I C,Z rr 0 3. Service Type ❑Priority Mail Express@ 11101 O Mil T1I Ili ill ill I I I ill I I I I1111111 ill El Adult Si❑Adult Signature nature Restricted Delivery ❑Registered MaiITM I ; ❑Registered Mail Restricted) i ' Certified Mail@ Delivery 9590 9402 5849 0038 3910 44 ❑Certified Mail Restricted Delivery ❑Return Receipt for i ❑Collect on Delivery Merchandise i 2. Article Number(Transfer from service label) ❑Collect on Delivery Restricted nalivery rl Signature Confirmatiol iTm I _ ❑Insured Mail ❑Signature Confirmation 7 D 15 1730 0001 4987 8513 'Fail Restricted Delivery Restricted Delivery li I PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt m o- .. L jr- 0 F F � C I A• L CO Certified Mail Fee Ir Ectra Services&Fees(check box,add tee as appropdate) r:I 0 Rat Receipt(hardcopy) $ `p ❑Retum Receipt(electronic) $ Postmark II C3 ❑Certified Mail Restricted.Delivery $ Here �0_ ❑Adult Signature Required $ []Adult Signature Restricted Delivery$ C3Postage - rq Total Postage and Fees � Sent Tp-- --------------- ---.._ --- -- NO., No S't�eet andA t: of�6$ox -' ,--_r, c` n t S m� C) 2�0` Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipient's retail associate. signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent Important Reminders. Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Glass Mail',Fish-Class Package service-, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which ■Certified Mail service is notavaU able for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified. ■Insurance coverage Is notavallable for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark If you would like a postmark on ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Retum Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. PS Form 38O0,April 2015(Reverse)PSN 7530-02-000-9047 Town of Barnstable Inspection Services Department . . p BAMMABLE =' Public.Health-Division.. Ica` 200.Main Street, Hyannis MA 02601 Office: 508-8Q 4644 FAX: 508-790-6304 Thomas A.McKean,.CHO March 2021 Fatima Hill 64-68 Seabrook Road �r Hyannis, MA 02601' ARE SEWER CWq TION EA DDLINE EXPIRED " a ., p_v r 64�-68:Seabrook$Road. ;,Hyannis A 307`017 Dear Property Owner, Your sewer connection deadline has passed. Please contact the Public ,Health Division. Office to provide an update relative to the status of property's connection'to public sewer (i.e. contractor name, DPW sewer connection:permit number, anticipated connection date) If you would like to request an extension, such request must be in writing addressed to the Board of Health (200 Main Street Hyannis, Massachusetts) or e-mail Sharon Crocker at: Sharon.crockerktown.Barnstable.ma.us within fourteen(14) days: Sincerely yours, Karen Malkus-Benjamin Town of Barnstable Health Division Coastal`Health Resource Coordinator karen.maIkus(d-)town.barn stable.ma.us Toww of Barnstable Inspectional, Services Department Public Health Division � 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 - Thomas A.McKean,CHO March 2021 Fatima Hill 64-68 Seabrook Road Hyannis, MA 02601 RE SEWER CONNECTION llEAALINE EXPIRED }64 -6$ Seabrook Road;,:Hyanms " x "y' A=307=017 " Dear Property Owner, Your sewer connection deadline has passed. Please contact the Public ,Health Division Office to provide an update relative to the status of property's connection to public sewer (i.e. contractor name, DPW sewer connection permit number, anticipated connection date.) If you would like to request an extension, such request must be in writing addressed to the Board of Health (200 Main Street Hyannis, Massachusetts) or e-mail Sharon Crocker_ at Sharon.crockerga,town.Barnstable.ma.us within fourteen(14) days; Sincerely yours, Karen Malkus-Benjamin Town of Barnstable Health.Division Coastal Health Resource Coordinator karen.malkus(D-town.barnstable.ma.us 1& T S�i 3 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments 64-68 Seabrook Rd ' h yC Property Address Y a� John &Lawrence Glynn, Roberta Wehmeyer rya Owner Owner's Name ijj information isM. required for every y H annis Ma 02601 12/26/2014 page. City/Town State Zip Code Date of Inspection YP tm L rb.l 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, 1. Inspector: use only the tab 0 'q _ Y e Y°U key to move r --- cursor-do not Sean M. Jones use the return key. Name of Inspector .. (► � S.M.Jones Title V Septic Inspection IC—V Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the -`` information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails _ ❑ Needs Further Evaluation by the Local Approving Authority Y 12/26/2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner : . and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection.,d-oes not address how the system will perform in the future under the same or different conditions of use. - — t5ins•3/13 ; e,.•«r; :M- -t* 4 Title 5 Offici Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 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: The dwelling located at 64-68 Seabrook Rd Hyannis is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 5 Infiltrators. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. ' A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 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 Y2 day flow t5ins•3/13 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 M 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal.coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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•3/13 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 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehme er Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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): 449 gpd provided t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is 2 M i anns a 0601 12/26/2014 required for every Hyannis t� page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacantDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is Hyannis Ma 02601 12/26/2014 required for every y f page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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: E Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) I Approximate age of all components, date installed (if known) and source of information: system installed 9/2000 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: .5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 6" t5ins•3/13 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 ,M 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is Hyannis Ma 02601 12/26/2014 required for every y f 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 3 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 4 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehme er Owner Owner's Name information is Hyannis Ma 02601 12/26/2014 required for every y t page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 Hi CapInfiltrators ❑ 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.): s.a.s. consists of 5 Hi Cap Infiltrators in a 32'x11' trench. No signs of past hydraulic were observed, soil was dry, no lush vegetation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C 13 Q A 3 -- ? 3 t5ins•3113 Title 5 Official Inspection Form_Suosullac Serge Disposal System•Page 15 of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 page. Cityfrown 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: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64-68 Seabrook Rd Property Address John &Lawrence Glynn, Roberta Wehmeyer Owner Owner's Name information is required for every Hyannis Ma 02601 12/26/2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 FORM30 C&w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS ' BOARD F H _ f CITY/TOWN W G DEPARTMENT 'o ADDRESS Q,M 5 0y`ew TEL PHONE Address __ 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 O Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: , Central ❑ Y ❑ N Equip. Repair r 7 TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST , ❑ P Waste Line:. H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: 11110 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.: S s, Flues Vet ,Safeties: Kitchen Facilities 16ink e 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 VIOLATION 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 RE R IS SIGNED AND CERTIFIED UNDER T E PAINS AND PENALTIES OF PERJ Y ' INSPECTOR TITLE DATE !� TIME P• A.M. THE NEXT SCHEDULED REINSPECTION P.M. i 410.750: Conditions Deemed to Endanger or Impair Healti 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 endarger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 41C.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(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 o der 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 Drovide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or sp,ead of disease. (J) The presence of Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Contrcl, 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-ourning 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, stock, 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 powcered, 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 batrtub 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 rai ing 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 enumera-ec in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health c+r 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 HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS ...� BOARD O�ET ' CITY/TOW N W , a D ART f ADDRESS M SV o o TELEPHONE Address Occupant ' Floor Apartment o. No. of Occupants No. of Habitable Rooms j No.Sleeping Rooms_—;_L-- No. dwelling or rooming units_ No.St r siA Name and address of owne _ cz Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Yf Gutters, Drains: Walls: z At Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: ZA Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: () . Hall, Floor,Wall,Ceilin : 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.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup. en.,Gas,Oil, Elect.: s, Flue e ,Safeties: Kitchen Facilities ink S ove 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 VIOLATIONV0 �4 ECKED 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 INSPECTOO s E O IS SIGNED AND CERTIFIED UNDER HE PAINS AND PENALTIES OF P R R INSPECTOR TITLE DATE TIME ° AA M. THE NEXT SCHEDULED REINSPECTION N P.M. 1 ti Conditions Deemed to Endanger or Impair Health or Safety 410.750� Co g p y 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 violations) 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 quant ty, 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. r common r n G Failure to provide adequate exits, or the obstruction cf any exit, passageway o co o 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'MR 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 CIVIR 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 nfestations 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. Jan 0'7 2008 11 : 11PM HP LRSERJET FAX 7 WAIVER##HV0iS1 �t�++ COMMONWEALTH OF MASSACHUSETTS Department of]Gabor Lac Industries and Department of Public NOTIFICATION OF IDELEADING WORK All sections of this form must be completed in order to comply with the notification requirements of M.G.L.Ch. 111, § 197, , 454 CMR 22.00 and 105 CMR 460.000 as most recently amendwl File Number: r. s,,:2 ICY USE) Contractor performing project Mark S.Bianco Licew a J."I aC 001055 I.,ead Paint Inspector Robert Powers Licreni.se'l.1f3651 Date of Inspecticn _..._..12/4/07 I!F low-risk deleading work is being perforeried, complete the following Hine: Property Owner: N/A Agent: s, Jan 07 2008 11 : 11PM HP LRSERJET FAX 13,. 3 A,ddress of Project BiD ilding Name (if any Floor. 1,._..._,. 'Street Address 64 Seabrook Rd. Apt. No. __•,_� �'::_ Ciity 11yannis Zip 02601. ._ Ie;Neleading Metho<WeVDry Scrapin�) Meat Gun Caustics Liquid Encapsulant Demolition Replacement Other fir"Other" selected, please explain ' C:;heck One: Dwelling is multi-family X Single family p SIart date 1/1 f/08 Completion date 1/28/08 'When will work be done: A.M. X P.M. Weeken&.1, X Project Supervisor's name Mark Bianco License # D(' O(J l )55 Property Owner Matt Glynn _ Address 12 Wing Rd. city Pocass€t State MA Zip 02559' _ 1"„lephone (508)527-7777 _ IrA case of emergency contact Mark Bianco F'ldo:oe: day (617)340-0816 evening (781)340-0544 (over) F t v • 2 Jain Old 2008 9: 02RM CHEMetr• ics, Tr:c. 540-788 1 Fomn WIM R ui est f)or Taxpayew ; Give form to the (Hay.,lanuavy 2M) identiftation NO imher and Certiflcation � roquester. Do not rlaper0tent o4 the Treasury send to the IRS. � Internet aaverme Service a y Dame(as shown an Vow income tax return) --- _GtfE_iifl_etrics, inc. ci. Business name,if different from above - --- —�- Individual/ - Cheek approprffthe tot: Sole proprietor J Other � Exempt from baoMjp Corporation ;- Partnersh a withholding _ _ address(nu nbEr,str;n:t,and apt.or suh3 no.) Requester's narvr _r.I a tc:-ass(optloraq i- 4296 Catlett Road u..c �i City,Vate,and ZIP cwie CaBve14on,11A2013>t ff List account number(s)hare(optional) ire UX-PayerIdentification Maamber (TlM Enter your TIN in ilia appropriate box.The TIN provided must match#Q name given on Une 1 to avoid ty,see the Part I Instruction' tin page 3. For other entities,it is rrour iawrployer identification number(EIN). If you do not have a nunitler,see How to get a Mon page 3. or Mot&if the account is in more than one name,see the chart on pa 4'for guidelines on whose number Empioy,er L ,1titiration numbw icy enter. 5 i 5 0 1 '! f 16 18 18.1 Q<r �of�tlfi��it9t1 Uride,psnalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identifloff ion number(car I am waiting for a number t.. 9: i;sw;id t 3 me),and 2.' I nun not subj(xl to bat'?,up withholding because: (a)I am exerio fiwm backup withholding,or(b)I have no?ut:a •:)"Awl by the Internal Revenue Semite ORS)tha:I am subject 10 backup withholdings a result of a failure to report all interest or divi¢ends,or(c)the IRS has rr 0eti me that I am no 1•:rnger subject to backup withholding, ar d i 3. I'"a U.S. person(Including a U.S. resident alien). C:erlilication instructions.You must cross out item 2 above'if you ha a been notified by the IRS that you are curTzrby s,ah;ect to backup tvlihhol-ding because you have failed to report all interest and dividends on your tax return. For real estate tran&t:, ions,if..rm 2 does not apply. For rriortgage,interest paid,acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement(IRA),and generally, payments other than interest and cKAdends,you are not required to sign the Cartic.,O:ic n, ,)ut you must provide your correct TIM.(See the instructions on page 4.) litigll5 �greaturo of — i^ler l tl.s person l�W , t i`' ®ate ® 01 !(.)U !"uif'pose of Form A parson who is required to file an information return with the ®Any estate (other than a foreign ast,*.tv)or trust.See IRS, must obtain your correct taxpayer identification number Regulations sections 301.7701-6(a)and 7(6)for additional.. C11N)ga report,for example,income paid to you, real estate information. tran,srlctions, mortgage interest you paid, acquisition or, Forelfp person,If you are a foreign pt3roon, do not use abandonment of secured property, cancellation of debt, or Form W-9. Instead, use the appro'l iriatt) Form W-8(see cconlAbutions you made to an iRA. Publication 515,Withholding of 1'ax or: llorresident Aliens U.S. lieraon.Use Form W-9 only if you are a U.S. person and Foreign Entities). (including a resident alien),to provide your correct TIN to the Nonresident alien who beconir's, Fin roside.,tt alien. pein;oh requesting it(the requester) and,when applicable, to: Generally,only a nonresident alien in6V.,iui:J may use the 1;+0ertify that the TIN you are giving is correct-(or you are terms of a tax treaty to reduce nr €rlini:n ite U.S.tax on ir,raiting for a number to be issued), certain types of income. Howev,�e rno:A lax treaties contain a 2.�Csrtify that you are not subject to backup withholding, provision known as a "saving it an niption frorls spaxt o car in the saving clause may permit aly e>.�:rnipYion from tax to 3, Clalm exemption from backup withholding if you are a continue for certain types of incorr*e -.n r:.fter the reclpiehl U.S. ett�nmpt payee. has o'thenrvlse become a U.S. resident.alien for tax purposes. Ttcxlrti.hf o requester gives you a form other than,Form W 9 tc If you are a U.S. resident alien who is relying on an ifiWuatt your 71N,you must use the requester's form if it is: exception contained r the saving ciai. s a tax treaty to sub,>tantially similar to this Form W-9. claim an exemption from U.S. tax n,l a,E :aiit types of incolTie, you must attach a statement to Fcjrin A•9 t'hat specifies the For federal tax purposes you are considered a person if y,oi following five items: 211PB1 1.The treaty country. Generally, ih41, must be the same: (9 An Individual who is a citizen or resident of the United treaty under which you claimed exemption 1tom tax as a S alos, nonresident alien. 4 A partnership,corporation,company, or association 2.The treaty article addressing the iricome. Created or organized in the United States or under the laws 3.The article number(or location) it' t'19't8x treaty_tha4 of tl°t ,United States, or contains the saving clause and Its exc:epAlons. Cat No.10231x Form W-9 (Rev.1-200U, J=jr1 0? 2008 11 : 11PM HP LASERJET FAX Ph ,i ~ Page 2 of 2 lin accwdanc:e with Massachusetts General Laws C. 111 §197,454 CMR' 2100 and 105 CMR 460.000,notice of the 1 to imd method(s)at' reir-111 nl or covering of paint,plaster or other accessible materials containing dangerous levels of lead is to be gr,•oi 14:`d and must be reccly ect by the Followrlug agencies,at least M(10)days prior to the beginning of deleading. N;-i FERTCA IONS MAY BE FAXED. 1- Department of Labor,Lead Program,Divislon'of Occupational Safety i 399 iWashingtoa Street,Sta Floor,Boston,MA 02108 FAX:617-727-7568 2. Ditltctor,Childhood Lead Poisoning Prevention Program Duel?urtMent of Public Health,Donovan Health Building,5 Randolph Street,Canton.MA 02021 FAQ::781-774-6700 3. ObUpants of dwelling unit 4. Pali other occupants of the residential premises,if any 5. Loim i Board of HealtlVCode Enforcement Agency 6- li IUMackusetts Historical Commission (if premises are listed on the State Register of Historic Z21D Morrissey.Blvd. Places,this notification must be made upon receipt of an Hociton,MA,02202 Order to Correct Violations or at least 30 days prior to FAX(lift)727-5128 initiating preventive deleading) 4110'hr1 'CA 11ON'S SHALL BE COMPLETED IN TIHEIR ENTIRETY,DATED AND SIGNED-INCOMPLETE Wrl"71F(CATIONS WILL Pd YF 1E:AC*<vFl."ED AND WALL BE RETURNED BY TILE DEPARTMENT OF LABOR&WORKFORCE DEVELOPMENT, ME(If owner or unlicensed owner's agent will be performing low-risk deleading work,complete the: PrrperiV 10m-iter A ent(s) r:dilrr�s:s ' . 1'elelp5one Number�L_)- 16crtifi;hat I nave complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning;Prevaostior.and Control Reg'lei.ionrt, 105 ' CMB 13130-171,fcr ownerlagent tow-risk abatement and containment. 1 further certify that 1 army agent will be performing tb: teollr,wing low-rask activities (s harre;ircled all that apply): appl;r'iing liquid encapsulant capping baseboards removing doors,cabinet doors.shutters 30pli ng euterlor vinyl siding covering surfaces th ar al I the infbrmation contained in this notification is true and correct to the best of my knowledge and belief. i D ter r Sl ed 1 t Kkcvisud 1,%4/2007 k'TOWN OF BARNSTABLE � Of LOCATIONr�/I. ` �f'� U/ SEWAGE # v VILLAGE ,`�"`r�t ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. .rY!/ d c_ S e,n 4, �. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) fJyi/7Glf���,�� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1 t e' c c t W TOWN OF BARNSTABLE BAR_W 4831 Ordinance or Regulation WARNING NOTICE Name of offender/Manager Address of Offender 1 v ..d�L. "R t/ 1. 1 MA _ - MV/MB Reg.# f t Village/State/Zip Business Name l 'V) m}/pm" onNr 200', 50*' Business Address �� �( `iL � > a � S: gnature _of Enforcing Office r Village/State/Zip Location of Offense S plgi h iD, gy 6 � f� J� t~� rr+ C r °/ �hEnforciing Dept/DivisionOffense �`t.�' 8 1Y V G &S4M f 11/k fl f !2 Facts 0 VKk-fWU)N(;- DOMA3r6e t &Jv VOA-1 ANif-) Pir-W-W-) i3v �tMV_3>fi N&��p ff This Grill serve only as a warning. At this time no legal °action has been taken.IX It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. ,. - .... ... _, r _....- ,_:,..,_ ... v ....., _. ._. _ . -...;- ..,- -.�.r-_ ^'it are ..r�.r�~�.�r—�• Y•v_ ,- .P. -....r �. q..- _ _ .... s _y TOWN OF BARNSTABLE BAR_W 4831 _ - Ordinance or Regulation sWARNING NOTICE }} Name of Offender/Manager /a-- I / ' .d t .. _w �, Address of Offender ,` 1 / f ' IJ MV/MB Reg.# f . Village/State/Zip f°'%r ' ' ' Business Name K?am/pm, on 1 4 20r�r' ,0 Business Address .1'"`,�, L , % /�' '. I r Signature `of Exforcing Officer Village/State/Zip Location of Offense {;- -f _' UL(iK '• ! . , ' . '"^:"` F Eriforcifg Dept/Division' - T" j ; ~^ Offense ' iY , Facts y4 s } .r a f..-i.� J' tY `..•^ '�4•r' '"r" i X�'� �..t'�' w- .�'�c J �; `y r r .,�'�.�..��. j.'r�"�j � �f �r � f` `i'j�,{''t, a r ��`.�a�":/� ' �•rt�l�`.s .' � fig' /��,C'� 1��j This will" se"rve'onlY'as""a+ warning`g• : At this time'no leg al/' &bt'ion 'has-been taken.It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2ppricatfon for Miopogal *p6tem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ,.Complete System ❑Individual Components Location Address or Lot No.&y—&r 5,FF j4. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 36"7�-? Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. vvs sa Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. B Description of Soil ro Nature of Repairs or Alterations(Answer when applicable) Sap vis Wit, 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 Certifi- cate of Compliance has-l `iss ed by this Bo �4��� Sign Date Application Approved b Date Application Disapproved for the following reasons Permit No. ��®(� Date Issued lJ, TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE_/ �� ASSESSOR'S MAP & LOT — INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) _%_AI�i�72 � �°�' (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r ( ci c - 70 J � " 40s f' No THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -'` Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rpprication for Migoml *p5tem Construction j3ermit + Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 5�;Complete System ❑Individual Components Location Address or Lot No. CrJ— S � l,C. Owner's Name,Address and Tel.No. Assessor's Map/Parcel --aC/2��_�_Q Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. IA&�� -< 04&_ • iS �GJl � s�"� Type of Building: t j! Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) :Other Fixtures (� Design Flow �Ati-11 gallons per day. Calculated daily flow �' 1 gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank ir� (Se A�—Type of S.A.S. 0r c i-t Description of Soil Nature of Repairs,or Alterations(Answer when applicable) SOT SIT 9U r.F Date last inspected: Agreement: �1 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 Certifi- cate of Compliance has-beerr ssi ued by this Board of H 991. Sig Date 'Application Approved b Date Application Disapproved for the following reasons Permit No. ��"®l� -: Date Issued -------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTI.FF 1/ that the On-site Sewage Disposal System Constructed( \`)Repaired ( )Upgraded( ) Abandoned( , f)b �t ,t P'�� F �— l t at �-t t4 �c�c vwt S hasbeen constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated I Installer Designer _ `/ O The issuance of this permit s l all nodb -s��o trued as a guarantee that the y-te filltfunction as des .ned.t! Date // Inspector C1` �, `1� -------------------------------------��—�— No. �Q�(, 7 Fee— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,, MASSACHUSETTS 1wigpoMt *p!5tem Con0truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(Obandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons uc on ust be completed within three years of the date of t��his��" ermlt. Date: ` Approvedfi �"�� � r 1 �J 1/6/99 NOTICE: This Form" Js To Be Used For the Repair Of Failed Septic Systems Only. . CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL -WORKS-CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS hereby certify that the application for disposal works construction permit signed by me dated /j7 , concerning the property located at (4A— 90 meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system t,--Tffe—re is no increase in flow and/or change in use proposed • T re are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: J A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation +the MAX. High G.W.Adjustment. _ DIFFERENCE BETWEEN A and B G SIGNED : DATE: [Please Sketc sed plan of sy em on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert I, i k' ,� Y O Q 4 4► i UNITED STATES POSTAL SERVICE First-Class MailPostage&.Fees Paid Permit No.G-10 • Print your name, address, and ZIP Code in this box• Public Health Division Town of Barnstable P.O.Box 534 Hyannis,Massachusetts 02601 fll�, ,�lil:li,3II: ►��Eillls�3:i,1�,�1it�l„I„dl„I�=ir�iii� . c- SENDER: ■Complete items 1 and/or 2 for additional services. I also Wish to receive the rn ■Complete items 3,4a,and 4b. following services(for an ru ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. ai j ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address d permit. y ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery fn ■The Return Receipt will show to whom the article was delivered and the date a C delivered. Consult postmaster for fee. 0 3.A 'cle Addressed to: 4a.Arti a Number d rt c3 6-7c-p E 4b.Service Type t° a ❑ Registered Certified ¢ to ❑ Express Mail ❑ Insured rn N ¢ ❑ Return Receipt for Merchandise ❑ COD ' 7.Date of Delivery 0 D 5.R ceived By: (Print Name) 8.Addressee's Address(Only if requested W and fee is paid) r I T ri:Signature: (Addressee or Agent) PS Fo 3811, ecember 1994 Domestic Return Receipt -VP 339 578 880 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail(Sea reverse San o u I Stat Code Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee LO rn Return Receipt Showing to Whom&Date Delivered o, Retum Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ EPostmark or Date 1®9U. a Stick postage stamps to article to cover First-Class postage,certified mall fee,and charges for any selected optional services(See front). i 1.If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service m window or hand it to your rural carrier(no extra charge). m 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the d cc return address of the article,date,detach,and retain the receipt,and mail the article. 3. H you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article ' RETURN RECEIPT REQUESTED adjacent to the number. 4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. co 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. 0 ` 6. Save this receipt and present it if you make an inquiry. d A::�c�90 '- FORM3o HOBBS&WARREN,INC. THE COMMONWEALTH OF MASSACHUSETTS �.-- BOARD OFPMAiT L-- CITY/TOWN a C� DEPARTMENT { " ' ADDRESS V .TELEPHONE / r/ Address ;r ' .< i ��F'1 /`�1 Occupant �l_l� Il` fa /Vl� Floor Apartment No. No.of Occupants No.of Habitable.R ooms No.Sleeping Room No.dwelling or rooming units No.Stories, Name and address of owner��- / �J [71 l 'Poo 7 �•-�L j f/ ) Remarks Reg. Vlo. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: ,, _ a _ . , ., I's",A I,.-- .<f.A I Dual Egress:and Obst'n.,r ❑ B ❑ F ❑ M Doors,Windows: Roof- Gutters, Drains: Lri- ' Walls: Fi ) __- ( (' ,-)0-r*-, Foundation: ..Chimney: ` BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: I\t STRUCTURE INT. Hall,Stairway: Obst'n.: i � Hall, Floor,Wall,Ceiling: Mot } Aj w t / i F) I'� (,_�1(-)�M Hall Lighting: V " Hall Windows: HEATING Chimneys: _ Central ❑Y ❑ N E ui . Repair �; ,I' \I� I NI I )o,77.. 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. Wirld. Doors Floors Locks Kitchen ;, Bathroom Pantry Den Living Room Bedroom 1 �f' _ �� J!1 )fit Bedroom 2 Bedroom 3 Bedroom(4) Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove d , Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: V t, r h /I)X 1 Wash Basin,Shower or T&7 I Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: 7. ' 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 j AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND ell j PENALTIES-OF PERJURY." All INSPECTOR : . A r tr TITLE DATE TIME �/ / P:M. THE NEXT SCHEDULED REINSPECTION ,�.� u � / t! AP.M. M. r r ` 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 heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of these 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 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations 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 the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it 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 OIR 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) Shut-off and/or failure to restore electricity or gas. (D). Failure to supply the electrical facilities required by 105 CMR 410.250(B); 410.251(A), 410.253(A), 410.253(B) and the lighting in common 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 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 an object, including garbage or trash, Which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (0) Failure to comply with the security requirements of 105 CMR 4110.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602 wMch results in any accumulation of garbage, 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 lead-based paint on a dwelling or dwelling unit in _.violation of the Hassachusetts Department of Public Health Regualt�ons for Lead Poisoning Prevention and Control 105 CMR 460.000. (K) f­Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or I*Af f ent to health -or dafety. 00 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 facilities 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 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: (t) 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 operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. Q) any defect in the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted plumbing heating,• gas-fitting, 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. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (H) shall be deemed to be a condition which may endanger or materially In"*r 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 1 ��',.-,�,,�,,_��".�_�,�._,,,_"',�",�",,;,i 4 t 1 P ""%L 'P.a�I�,.:1,,,�`1��i�,� �:­Ii��,7,,'1-;,��'.*­."�i��o,�1'y;,:���;,"".��" ;l,1',-,,,-"�I'''l7il,,",",,,Io,,�,�l",'�_�l.��,"'".,,�­,, - op , Y'h }a yZ q - Y ` t"1.�,,�,�"""4'-�'..-"*,,�"1,_�_r,"�1,'.,y,-�,o�,,,I,,,,,,-,,I1,.!,.�*1�' .*"�)I�:t'�'�,-I, -�T,Ir`,".' 'ft�".",�� `� �" M ,a ,.s TH ,COMMONWEALTH'OF MASSACHUSETTS "" g _ `; r 4"FORM 3Oi &W 41s 8 WARREN 1t,4 e� r s r r 'f ''` I i ,I.l 1r,'�,�b,.,,,,I:��I j�r'�.,:rrI;",-1 2��b.'-,,.,,,.�':-"r,,I�J�..r',,�r_,;,.:1,-,r_I�""'j",'­��-b,,�'.,,�:�.."I,t�i 1���,�.,1,,' -..,�"*rl.,.�,r�".I:Il�r_"',._I,.,—L,�r��1-��I,�,:I,11��-.I, ",�','.,Ir.',I`,���1 l�,,1�l:�A�I��,;`I r L1 A.-,.�r r�J�I,,��l I-�,,1�-_,,,tIr.,�,_,'�­.,�O�';...I".,.­.,I'r,,,�rg�,,r,"_,-.I rr�-,,IZ''I,:'.��I�r�q;j.:..1,_.b�.IIl':�i�,I��1,�'-.I;I,��.-�..,.�,1..Xr�III,r-,.--I r,,�.,'".�,I.!.�,r:�.I,.�b�""l 11�,,I-,,'.1.'.'.0 r.,_:.. ��.k,.,,r�t_,�.�V,� '",;�,�.,1I 1 I��r�I�l 1r';����.`b 1­r I,,I.r.,�I.,.r"T�,r._-'�,r,J I.r,Ir�r-r V._r����:..­�r,6r!-'�r0',.�b.,,I���,rI,I_'. r,,',�'�'1.,.,.�%�,.Ir;,d'�(��"j I+rI".r�,"� ,r�t,1­,I;0,1",�r�I'��b'Vr,-,_l'"— '�',r,�,",­_�1.r;--4 I�';§:',L,b",i-., I--,r 1��,",�i%4�,%L N .,r y1-i r,����r 1_A�ti1,t,',:";I,r�'./I1�4fI_i�.I,,ff',1j�r�1,�j1�l..,II�,!�I��'4I.-r,:,i,.��1�,�Ir� T��"-_* ,_1�',0., i s :i {h J B O R D O 'H�FANLT H , ` # . - " `, t 6 �,rV +�/g�/) u � ":r l/ F&P CITY., OWN _ r,: "'' r tt s } r r�! '� r y ,3 i 5 n . . i /— o D ARfM NT'� �� 6 s, , s at C u �'" 1 ti,4a�jt r t �ADDR@ S �' t�� // r ' o� s+° t,a } k 3 t g ! f. t ' a f:e I (/`yy[,7'.yY!/7 �L/ P a,. ' A e ,;;" (�, ° TELEPHONE + i : . f -� c �. ja �^ _� ,� s 5 'i S A k 1 1 Addres Occupa` „ .. � fi a ,� � Floor Apartment No No of Occupa s £„ y+, No.of Habitable Rooms ,3 Nb'Sleeping Rooms,✓ ;,, }, No. dwelling`or rooming units, z a:, t ryies �'i r /� ' h 9 Name and address of owner ;C i� 'f 1( j np::. 4 tip" ti fir,+;.' , r� #al,; "` tr +'°Ca! P i f I t9 1� �r '� x Remarks Reg Vio YARD,, OutBld s 'Fences :,P r K 1z 4 ", 3 ' 'Garba e and Rubbish ' ( / \ , '�, , I '# 2,1 r' Cgntalners � `"' ':"' ' / A�,�i yxry Draina e U� 1l Infestation Rats o�other; t. $TRU,CTURE,EXT. Ste s;Stairs, Po.'rcheS: r , . ;:p t-arc :.:bual E ress and Obst n , t7 '°❑ B,x ElF EM _' . Doors,Windows:. ,. :J ! ,( {� ..; . ' Roof - 1 r Y 1 )' y �'7Utter`S, Drams.._;,., � � rr,5 '-'r P`f _ ,x:;`s ' �� Walls I, € P, _ , " ` i N'Mtn >:Pi - �.t , k i �,, ,,�, + 3 r- i ,} s 2 -3 a Foundation g i a r•. , a+s ,xfA s r r Chimne d 'BASEMENT Gen Sanitation ,` r" ° _ , �' - ' 4 §, ( Dam ness i s` a r E t a s Stairs ° k• LI htln S, ' e n pit. t x.., ;.'STRUCTURE;INT ,v- Hall,Stairwa ,`', ' 'r , f' ,,,i t r r a `d a Hull, Floor,Wall,Ceilm ;, , 1 ,;, „r �� ;: ;.;1 �„ r 2 ed . its , [., 1 a �/,.3 r 1 '.�,*�,y e a i 4�1 ' r Wall Li htin Hull Windows „fix. ;> 'r gt1HEATING c Chimne 's _ }!" ' k I 5`Cent"raf ❑Y` ❑ N,' . E`ui' : Re air, -. - 'TYPE.; l= Stacks,;Faues Vents � : ,PLUMBING" 'Su I Line. ,., r 1 a _ :,f�� F :-ah M$ ❑ 3T ❑ P. ';Waste Line f' �� "�i 1, �' = H';�W Tank s Safet and'Vent s r, t r I _,,.f �1° r _ t'tin ,+i4� : �! � ��, ELECTRICAL`' s Pan I `aM r F,a =;t s,, r t Zj," P,4 ,,f^ ,.�{.,+ m ; :f e s,_ eters Cir "5t 4 f Y„ k': '" t 4 i �, 110 ❑ 220. Fusin ,Grnd ,. « 5 r.,; P si; e � � ,> � rt %AMP Gen Cond Distrib Box t' �t F , r'. �' a , , G.en Basement 1Nmn , , i 1 4 DWELLING UNIT p f: A > # `j '` i Ventil L"tn 7 Outlets.: Walls.' '.Ceils.` Wind;` Doors. Floors Locks KItHen w�'' ' 4I , :' 7 j. a x y,�r�E a= i. i i s ', .3 r" Bathroom,"' r t, { PantC 4. 1, rt�� _,. a = u'$, r -:i i u (Sq E 3 a 2-S r r :.;t is Y R° ; $, Den i� ,. r a lf. �, .�, ° b ".Lavin Room t� - ,t,,,: Bedroom i � ss 4t P Bedrpoml 2 �Y fi 9 7 �f -7 � it j �i H A, :,) BedF.00m 3 p« ` x. . , <. ;" ., �,t l` Bedroom'4 , _ y q 4 a r1, 1.i Hot Water Facil S�u r Ten:; Gas,Qil Elect ,� ¢� �' I r ` Y = ... „-, ,•S.t,a Flues;••Vents,° afetles r ;_.° x _ fi :, Kitchen Facihtles Sink r. ,. tf� .r �St, # ' ' _a, dh� f'' § f Bathing,Toilet FaciL Vent., Plumb ;;Sanit n . :: r :'' i°`{""fi Wash Basin,Shower or Tub: � f 1,4 (" � �,-v " infestation :t 4':� ��Rats;Mice;Roaches or O er::"" �'I `"�'I ' P' Pj i"� ,, r' `'d 'f tess Dual and-Obst`n: I�b '` General Buaidin Posted P , Locks On Doors: "" , �. , ' ' ONlt OR'MORE OF'THE-VIOLATI`ONS CHECKED ABOVE IS A CONDITION.WHICH, • ° U �' � ' f 1 k v J 4 - 1+ - j. ➢ T k P 1+ MAY;MATERIALLY IMPAIR THE HEALTH. OR SAFETY:AND WELL BEING 6F THE ' q 7 ::r OCCUPANT AS ,DETERMINED"BY,105CMR 410 750; OF. THE CODE OR THE,`; I I AUTHORIZED INSPECTOR:(See Over) r, si Y l � `' THIS INSPECTION REPORT IS SI DIED'AND CERTIFIED UNDER THE PbIN$ A D ' ' .t PENALTIE OF PERJUFIY " D � c,;e INSPECTOR ff TITLE J t , , t ,,l,.,,I,,,'�­�'�k� r- „' A.M . l{ 9 ls" TIME P�M :�: DATE A M . r. , hT THE NEXT SCHEDULED REIN SECTION � � P!`M « R prI 1 , r. "ay. ...,.i,. ._..`^.. 4, �' _. .. ;_ )t".. ''rz `a `'i: 1.. , �:: 1 t;. �x .n , �S 1i34 . j. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP PARCEL ; e� Property Address: LOT Owner's Name: voMPS Aje(_jlck-,,t)er Owner's Address: R E C Date of Inspection: it. - APR o 7 2003 Name of Inspector: (please printE)oui3las A.Brown Company Name: f) Wn Septic Inspections TOWN OF SARNSTABLE Mailing Address: oP1 pmv 1eG HEALTH DEPT. Centerville, "A 02632 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/Seec�iojl 5.340 of Title 5(310 CMR 15.000). The system: Passes y Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: - O� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within30 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. Title 5 Inspection Form 6/15/2000 page 1 'R, vo R,� )CA/2" Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: L�/ -G 6rccll id r�✓Ni s Ah 0Q Owner's Name: 'j-6mes New der Owner's Address:. S c, Date of Inspection: 2-G 0-_� 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: // f` /N. -ta /ed c)o 7NI` N'e. (5 1^I �/i•y 4eff V1Cx( v !,,w sc)V YV jfday- B. System Conditionally Passes: one or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Gc1- C ra Crr��fc _ Kr� Owner's Name: �,r►.�� �,H, 9 C Owner's Address:_ <&m Date of Inspection: 0,- Ct 0 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment- - Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the NA 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 buy 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: Sc-c:bMCA� nioM c, o G61 Owner's Name:_ �' Owner's Address: Scdv\ c Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections; Yes No r/$ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ndin of effluent to the surface of the ground or surface waters due an overloaded g Im u to o aded or g 1�' clogged SAS or cesspool _ static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cp�_sssppool _ P%iamd depth in cesspool is less than 6".below invert or available volume is less than%Z day flow _ :�: t�eglmred pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped L-12A�,yy_portion of the SAS,cesspool or privy is below high ground water elevation. any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ >-iiyportion of a cesspool or privy is within a Zone 1 of a public well. _juy portion of a cesspool or privy is within 50 feet of a private water supply well. vAny 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 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.] (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 system the system must 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 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 feet of a tributary to a surface drinking water supply 1 " _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped 1 " Zone H 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 Page 5 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: G '-1-cs 5eAfml r 2(� N C�2G C� Owner: 0_0111e& 'NeW10Cjer Date of Inspection: - CP -03 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 V 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? V/'� Was the site inspected for signs of break out? Were all system components,excluding the SAS,Iocated on site? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the b es or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes ..Existing information.For example, a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 I , Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Co`t 'G i � Owner's Name: Owner's Address: �..^P Date of Inspection: RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): LI DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):..9 q0 Number of current residents: / Does residence have a garbage grinder(yes or no): 6�0 Is laundry on a separate sewage system(yes or no):No fif yes separate inspection required] Laundry system inspected(yes or no):/4Q Seasonal use: (yes or-no): Water meter readings,if available(last 2 years usage(gpd)):.g-�9,C 0y, _ C;-' J_L 5 c+; 5 C Sump pump(yes or no):Lt Last date of occupancy: v t r',j� !ca` !3 c� COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— ^ � Industrial waste holding tank present(yes or no) [\ Non-sanitary waste discharged to the Title 5 system(yes or no) Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):— 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 any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be ` obtained from' system owner) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components.,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(ves or no): Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address% 0 41-& � 0 Owner's Name: ]c ,� — Owner's Address: Date of Inspection:�2C2 —0 3 BUILDING SEWER(locate on site plan) Depth below grade: 1 2 Materials of construction:_cast iron _4✓ 0 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade:" J Material of construction: oncrete_metal_fiberglass;polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) / _ Dimensions: S '7 " C. � yl 10 C9 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 D;Aance from top of scum to top of outlet tee or baffle: C� Distance from bottom of scum to bottom of outlet tee or bale: 0 How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): S S � o h �� cc opc,N�- k"X t r4 of C.Com kNy " GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal fiberglass_polyethylene_other ^1 (explain): — ! v 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: Comments(on pumping recommendations,inlet and outlet tee,or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,y-GOA e,'-rt�c�i�_ NI , O� Owner's Name: Owner's Address: Sc Date of Inspection:a. G © 'k TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constriction: concrete. metal fiberglass_polyethylene other(explain): Dimensions: Capacity. gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float"switches,etc.): 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 distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or ou of box,etc.):_ s s i3 0 PUMP CHAMBER:__Oocatd on site plan) Pumps in working order(yes or no): I v Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO TION(continued) Property Address:&N -Ggi !&_11AIMI . 1z Owner's Name: ,1)go Owner's Address: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: _,'erflow cesspool,number: V innovative/alternative system Typetname of technology: "t►y �`-t�C�ryCC Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): . . n S loW i-iGX�0tS krJ Cat 15 X C\V\ 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 or 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: N Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner's.Name•_ Owner's Address:_ S c/\,\ ,(, Date of Inspection: a — CD —0 3 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. 0� WOO -= p O O r A7�S -iy -I'D -S - 7) Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INF TION(continued) Property Address: — �c Owner's Name: Owner's Address: `C p Date of Inspection: t SITE Ex" Slope:.v i a i- Surface water%fJ o N e Check cellar: '7r.f Shallow wells N v Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: r+c..a C7 A J%,e(- i S' NO W co C.r C'N l ._'.• •w ."`y...ry �..d t+.-gy.wry Av{.•wr`D+^•4^"`+w"••^. .•r+'4"+.r"p'lw �. - _ .. � ^, rn��t .,._ _ .,� �..w�'Ff,�"�71'S�`ytS..,t�ny.�('./1•�.^-.ram 71, FORM30 �aw HOBBs&WARREN TM THE COMMONWEALTH OF M.ASSACHUSETTS BOARD O.FeHIE-A.LTH,`` :M- CITY/TOWN'' DEPARTMENT � � m&o� / t(//,✓� j ADDRFTSS M TELEPHONE (P t A/ Address ` Occupa Floor_I Apartment No. No.of Occupar s �Y� No. of Habitable Rooms No.Sleeping Rooms' No. dwelling or rooming units o.St r3ies• Name and address of owner �Mv �'Al9V Remarks Reg. Vio.;�/Y'� YARD,,__,_,. Out Bld s.: Fences: 0, A ) ),A 14� ,t Garbage and Rubbish ) N / / rook V ) Containers: /j/� Drainage (/0� Infestation Rats or other: i STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: d k t I O_ ,o �,;-"'� ❑ B ❑ F ❑ M Doors,Windows: IAJLI\lu Roof 'M/V6 1 IMIZ I-�" #r-t ' Gutters, Drains: "" Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: . , „ Dampness: I A l G/ X._. LA/ y i - Stairs: Lighting: STRUCTURE INT.,;y 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.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks t Kitchen -Bathroom —Pantry Den —Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect..- Stacks, Flues,Vents, Safeties: Kitchen Facilities Sink Stove 00, Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: p f Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: I r Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH x 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." 6A, INSPECTOR T TL�E (7 r �� v A.M. DA TIME ( / : '1 „ AM. 1 THE NEXT SCHEDULED REINSPECTION ;r 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 AMR 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 410.603, 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 dwellirg 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, stock, 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 CM'R 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 bathtuo 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. L .,fie;-`"-.-"r"" ,.,:.t�---•.r•..l-:....j„.�`w-rwgaii.�.,Rr^.Y"••, _ _. ;; ; �, - ?[S eFORM30 �sW HosBsaWnRaeNT" THE COMMONWEALTH.OF MASSACHUSE " . � o B OAR D O ..: H�E LT`H CITY/TOWN � t• ?: •... ✓ a {t DE?ARTMENT ADDRESS G�'N Sey`0 �1i 'iF�y„e �y„7 1R! 7`. .•����!J /���r ' TELEPHONE ,%f � Addres .��.� .....� -,^ l Occ'upa n, , j l��t`t , , ° Al Floor Apartment No. No.of Occupants ' No. of Habitable Rooms No.Sleeping Rooms No. dwelling or rooming units No.Stories. o' (t t "x * 'G ° t e r t r, kr1/ flt�r ��f Name and address of owner f ._fir' '� I� �f `ta r Remarks Reg. Vio. y YARD Out Bld s.: Fences: r Garbage and Rubbish IP�1 f i 1 Al 1AA .` V'r-"I d: Containers: Drainage Infestation Rats or other: r STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n. t I ,I ❑ B ❑ F ❑ M Doors,Windows: ' 1 t6 ' Roof Gutters, Drains: �'t. ,/� '.'� Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: t x I' ' Dampness: ffr1 � 1 Stairs: v .. F Li htin : STRUCTURE INT.,-:* Hall,Stairway: Obst'n.: " Hall, Floor,Wall,Ceiling: , Hall Lighting: r' Hall Windows: ' HEATING Chimneys: Centr`ak.._ ❑ Y4 ❑ N Equip. Repair -TYPE: Stacks, Flues,Vents: ^ --PLUMBING:-- �. Supply Line: El MS '❑ ST '❑ P Waste Line: jl 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 Pintry Den Living Room Bedroom 1 Bedroom 2 Bedroom(3)�- 3 Bedroom 4 Hot Water Facil. Sup.Ten., Gas, Oil, Elect.: (. Stacks, Flues,Vents,Safeties.- Kitchen Facilities Sink i u Stove ' Bathing,Toilet Facil. ' Vent., Plurn'b.,Sanit'n.: ` Wash;Basin; Shower or Tub Infestation Rats, Mice, Roaches or Other:..-�,... E ress,,, 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) y ,R "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS-AND - a= PENALTIES OF PERJURY." �f r. " I f f INSPECTOR t., TITLE ti f t ti TIMEDATE :. Al, ABM'; THE NEXT SCHEDULED REINSPECTION. t ? P:M. , tit 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. 1