HomeMy WebLinkAbout0202 SEVENTH AVENUE (HYANNIS) - Health 202
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Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'•- 202 Seventh Ave.
Property Address
Owner Susan & Philip Lembo
information is Owner's Name
required for every Hyannisport MA 02647
page. City/Town 10/25/2017
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
El drawing attached separately
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Mrs-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55
202 Seventh Ave. t=
r3r,1
Property Address �•ry,�:
Susan & Philip Lembo'
Owner Owners Name
information is / .
required for every Hyannisport V MA 02647 10/25/2017
page. City/Town
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information ,c filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
kee the return Name of Inspector
y
Ford Septic Services, LLC
Company Name
P.O. Box 49
Company Address
Osterville MA 02655
CitylTown State Zip Code
508-862-9400 S12482
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 Ev ation by the Local Approving Authority
11/6/2017
Inspec Signature Date
The m inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit.the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
I
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
H u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner Owners Name
information is
required for every Hyannisport MA 02647
page. City/Town 10/25/2017
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:
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.
i
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):
i
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�A.A,•' 202 Seventh Ave.
Property Address
Susan & Phil Lembo
Owner Owner's Name
information is
required for every Hyannisport MA 02647
page. City/Town 10/25/2017
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•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection_ p n Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner '
information is Owners Name
required for every Hyannisport MA 02647
page. City/Town 10/25/2017
State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3/13 -
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner Owner's Name
information is
required for every yannisport MA
02647 10/25/2017
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
❑ 1 ❑ 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.
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c;
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner information is Owner's Name
required for every Hyannisport MA
page. Cltyrrown 02647 10/25/2017
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): 3 Number of bedrooms (actual): 3,
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner Owner's Name
information is
required for every Hyannisport MA 02647
page. City/Town 10/25/2017
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
information in this report.) ❑ Yes ® No
Laundry system inspected? El Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
unavailable
Sump pump?
❑ Yes ® No
Last date of occupancy: unknown
Date
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? El 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner Owner's Name
information is
required for every Hyannisport MA 02647
page. City/Town 10/25/2017
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: unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® . Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner Owner's Name
information is
required for every Hyannisport MA
02647 10/25/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) .
Approximate age of all components, date installed (if known)and source of information:
system installed -unknown
Were sewage odors detected when arriving at the site? El 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.):
Septic Tank (locate on site plan):
Depth below grade:
7"
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ pot eth lene
Y Y ® 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: 1000 gal.
Sludge depth: 1
15ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner information is Owner's Name
required for every Hyannisport
MA 02647 10/25/2017
page. City/Town State ZipCode
Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 1
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 14
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tees were present. no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: n/a
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass 9 El polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee,or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
l5ins•3113
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
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner Owner's Name
information is
required for every Hyannisport MA 02647
page. City/Town 10/25/2017
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 9 El polyethylene El other(explain):
N/a
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
l5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner Owner's Name
information is
required for every Hyannisport MA 02647
017
page. City/Town 1 ate of inspection
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 none
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.):
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):
P
If SAS not located, explain why:
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
202 Seventh Ave.
Property Address
Susan & Philip Lembo
Owner Owner's Name
information is
required for every Hyannisport MA 02647 10/page. CltylTown 25/2017
State Zip Code Date of Inspection
D. System Information (Cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number.-
El leaching galleries number:
® leaching trenches number, length: 1
❑ 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.):
The trench was dry and clean. A camera was used to inspect.
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
202 Seventh`�M e Ave.
Property Address
Susan & Philip Lembo
Owner information is Owner's Name
required for every Hyannisport MA 02647
page. Cltyrrown 10/25/2017
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.):
N/a
I5ins-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
202 Seventh Ave.
Property Address
Susan & Phil Lembo
Owner Owner's Name
information is
required for every Hyannisport MA
page. Cltyrrown 02647 10/25/2017
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
BACk goo
ao
3
A Q
106 ay
a « 91
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Seventh Ave.
Property Address
Susan & Phili Lembo
Owner Owner's Name
information is
required for every Hyannisport 02647
page. Clty/rown State Zi Code 10/25/2017
P Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water. 8' +/-
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:
Topo and water contours map
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
see above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
Commonwealth of Massachusetts
Affim Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Seventh Ave.
Property Address
Susan & Phil Lembo
Owner information is Owner's Name
required for every Hyannisport
MA 02647 10/25/2017
page. City/Town State ZipCode
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
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
is TITLE.5
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 202 Seventh Avenue +
W.Hyannispor A 02672
Owner-'s Name: Clernenicio Tories
Owner's Address:
Date of Inspection: January 20, 2012'
Name:of Inspector: (Please Print} Janies M F6rd
Company Name: JamesM. Ford:
Mailing Address: P.O.Box 49
Oster•ville,MA' 02655-00.49
Telephone Number: (508) 862-9400'
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that thC-m brm reation orte,8
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. tam aIT.EP` '
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sy `�
stem: .
N
✓ 'asses µ
t_u ditionally Passes
N e s Further Evaluation by,the Local Approving Authority51-1
co
Inspectors Signature: Date: JanuaiT 23, 2012
The system inspector shall submi copy,of t.�is 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 c.:vner 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
***.*Tliis report only,describes conditions at the.time.of inspection and under the conditions of use At that'
time. This inspection does not.address h,ow�.the system will perform in the future;under the same or different
conditions of use.
Title 5Inspection Foun 6/15/2000 page 1
Page 2. of 11
OFFICIAL INSPECTION FORM-NOT,FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 202 Seventh Avenue
W.HyamnisUort
Owner: Clemenicio Torres
Date of Inspection: January 20, 2012
Inspection Summary: 'Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
~ Comments:
B. System Conditionally.Passes:
One or more system 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 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 enfiltration 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.
f
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
ND explain:
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
ND explain:
2 ;'
r�
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 202 Seventh Avenue
If. Hvannisyort
Owner: Clenienicio Torres
Date of Inspection: January 20, 2012'
C. Further Evaluation is Required bytheBoard 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 5.0 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
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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system:has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used.to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of arrunonia 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:
Page 4 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION. (continued)
Property Address: 202 Seventh Avenue
1V Hvannisport
Owner: Clemenicio Torres
Date of Inspection: January 20, 2012
D. System Failure Criteria applicable to all systems:
You must indicate either"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%z day flow
Required-pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_. .
✓ Any portion of'the'SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface 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 coliforcn 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 forma
No (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
gp d
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
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 202 Seventh Avenue
W.Hvannisvart
Owner: Clernenicio Torres
Date of Inspection: January 20,2012, .
Check if the following have been done::You must indicate"yes"or"no"as to each of the following:
i
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 7
✓ 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:
Yes No
✓ 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)]. +;
yr t
Page 6 of 11
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 202 Seventh Avenue
W.._Hyannisport
Owner: CleMenicio Torres
Date.of Inspection: January 20, 2'012
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have agarbage grinder(yes or no): . N/a
Is laundry on a separate sewage system(yes or no): .N/a [if yes separate inspection required]
Laundry system inspected(yes or no): no
Seasonal,use(yes or no): no
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no).: No
Last date of occupancy: Stanrner�use .
COMMERCIAL/INDUSTRIAL
Type of establislurient:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sq/ft etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes of 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: Unavailable
Was system pumped as part of the inspection.(:yes or no): _
If yes,volume pumped: gallons-;,How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system.(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology.i Attach a copy of the current operation and maintenance corntractu(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
Date of installation unknown
Were,sewage odors:detected when arriving at the site(yes or no): No
6.
• X
Page 7.of 11
OFFICIAL INSPECTIONFORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE"DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 202 Seventh Avenue
W. Hvannisvort
Owner: Clemenicio Tories
Date of Inspection: January 20, 2012
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron _40 PVC other(explain):
Distance from private,water supply well or suction line:
Comments(on condition of joints,venting,:evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 2"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
other(explain)
If tank is metal list age: Is age confirined by a Certificate of Compliance(yes or no): '(attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 21f ;
Distance from.top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: . . I"
Distance from top of scum to top of outlet tee or baffle: 6tr
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuriu stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence.of leakage;etc.).
The tees.were present.. The liquid level was even lvith the outlet invert There did not appear to be any signs of leakage
GREASE TRAP: ' None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee.or baffle:
Date of last pumping:
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: 202 Seventh 4veniie
W. Hyannisport
Owner: Cleinenicio Tories
Date of Inspection: January 20, 2012
TIGHT or HOLDING TANK. None (tank must be pumped at time of inspection)(locate on site plan)
Depth.below grade:
Material of construction: _concrete _1,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: Notre (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 out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments.(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 202 Seventh:Avenue
W. Hvannisport
Owner: Cletnenicio Torres
Date of.Inspection: Janua�T 20,2012
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:: 1 trench
leaching fields,number,dimensions:
overflow cesspool;number:
Innovative/alternative system Type/name of technology: .
Commnents(note condition of soil,signs of hydraulic failure,level of ponding;damp soil,condition of.vegetation,etc.):`
There did not appear to be any signs of failure A camera ivas used for the inspection Bottom to grade ivas app. 2'
CESSPOOLS: None ' (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:, None (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.):
.RYA.
AL 9
,y
Page 10 of 11
OFFICIAL INSPECTIOON FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 202 Seventh Avenue
W. Hyannisvort
Owner: Clenzenicio Torres.
Date of Lispection: January 20 2012
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.'
Sl�dtr
ABC
l3
to ty
a 1(0
X
1
w
Page 11 of 11
OFFICIAL.INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 202 Seventh Avenue
W. Hvannisport
Owner: Clemenicio Torres
Date of Inspection: JanuarT 20,2012
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water. 8+/- 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: Topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-.explain':
You must describe how you established the high ground water elevation: .
Using Barnstable topographic and ivater Contours maps the maps were showing approximately 8"-+I---to ground water at this
site.
This report has been prepared only for the septic system and components described.herein: This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
frntction properly in the future: There have been no warranties or guarantees, either expressed, written or implied,
relating to the septic system, the inspection, this report and/or any components of the septicsystem which.have not
been located and inspected.
i
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
LISPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
cSTown of Barnstable
Health Division
200 Main Street
Hyannis;MA 02601
Hit 111111,11 lill fit it it Ili Ili il113 i 611t i i i I I J iM 1li1i'
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. ign
item 4 if Restricted Delivery is desired. Agent
■ Print your name and address on the reverse Addressee
so that we can return the card to you. i c d by Printed N Cate. ;,,f Delivery
■ Attach this card to the back of the mailioiece, c
or on the front if space permits. ,. -
D. s delivery addressVd
nt fro m 1? es
1. Article Addressed to: If YES,enter de ivdress Belpw: ' o
70 1
/► - JIF
� 'y.
OAl
l 3. Service Type
Certified Mail ❑ Express Mail
❑ Registered ■Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number 7005 1160 0000 01-91 ,2298
(Transfer from service label)
PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540
Certified Mail#7005 1160 0000 0191 2298
OVIKE rowti Town of Barnstable
Regulatory Services
�* BARNSTABLE,
9 v1AS8. 0, Thomas F. Geiler,Director
oOAr�bN1 0. Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
May 4, 2007
Clem& Margaret Torres
172 Harland Road
Norwich, MA 06360
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 202 Seventh Avenue, was inspected
on May 4, 2007 by Meredith Morgan, Health Inspector for the Town of Barnstable. This
inspection was conducted on the basis of the rental registration in accordance with
Chapter 170 of the Town of Barnstable Code.
The following violations of the Town of Barnstable Code were observed:
1� 70-10—Smoke Detectors and Carbon Monoxide Alarms. Inoperable smoke
detectors in basement and on 1"floor; inoperable CO detector on I" floor near bedrooms.
You are directed to correct the violations listed above within twenty-four (24) hours
of your receipt of this notice by repairing or replacing smoke and CO detectors so
they are working properly and installed in accordance with Mass State Fire Codes.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Q:\Order letters\Housing violations\Rental ordinance\202 Seventh Avenue.doc
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
;PER ORDER OF THE OARD OF HEALTH
omas A. McKean, R.S., O
Director of Public Health
Town of Barnstable
Cc: Meredith Morgan, Health Inspector
Q:\Order letters\Housing violations\Rental ordinance\202 Seventh Avenue.doc
FORM30 C��� HOBBS&WARREN`M THE COMMONWEALTH OF MASSACHUSETTS
RD OF HEALTH
CITY/TOWN
141 EPARTMENT
Pr g
'q A RESS /�\J� /ry
GSM s� 1 �Y lJ�
,, TELEPHONE
Address �I)q�Q0�����k).NApo SOccupan
Floor Apartme t No. W.of Occupants
LVK7
No.of Habitable Rooms_ No.Sleeping Rooms
No. dwelling or rooming units No.Stories l , l� 1 ,,I,,
Name and address of owner M4 HQ_vO rJ I-4-a YWoo( ed... Iyfl/✓wt 011 4 C��p
lJ Remarks Reg. Vio. V��tOV
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:
Chimne :
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Li htin
STRUCTURE INT. Hall,Stairway:
Obst'n.: J
Hall, Floor,Wall,Ceiling: 1d.P
Hall Lighting:
Hall Windows:
HEATING Chimneys: S
Central El El Equip. Repair
j
TYPE: Stacks, Flues,Vents:
PLUMBING: Su ply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink O
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTI S /s /
INSPECTOR TITLE b=��WVI �/y ���V
C A.M.
DATE TIME
A.M.
THE NEXT SCHEDULED REINSPECTION 1 P.M.
I
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation,any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254..
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, ruobish, 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. t
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
_e_C,�p��__
ada_ _se � � �-�� � �,
Parcel Detail Page 1 of 3
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Parcellnfo
Parcel ID'245-080 Developeer=LOT 535 & 537
Lo
Location;202 SEVENTH AVENUE Pri Frontage 190
Sec Road , Sec _.
Frontage
- - - - _..._.---------------
r-..-- _..--- -.-_ ....".",... --...,._ ... ...__.._.
Village HYANNIS Fire DistrictHYANNIS
- ... ......... -._ ..- __,._ .- - _ �_..-��...-
Road Index, -_ __.... .,_.�,.-...
Sewer Acct 1470
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Interactive
Map 1NK
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Owner Info
owner TORRES CLEMENCIO & MARGARET TRS Co-owner TORRES FAMILY NOMINEE TRUST
.......... .......... . __....... .... .
Streets ,172 HARLAND RD Street2
....... _ .........
City NORWICH State CT zip 06360 Country US
Land Info
_............................................. .. .........
Acres 0.18 Use Single Fam MDL-01 Zoning RB Nghbd;0113
------
P 9 P y
To o ra h Level Road Paved
Utilities ISe tic,Gas,Public Water Location .Water View
Construction Info
Building I of I
- ...._
Year 1951" "- Roof Gable/Hip Ext Wood Shingle
Built= Struct` Wall
Effect Roof r Roof°Asph/F GlsiCmp AC None
Area• Cover Type
..........
style Ranch Int`Drywall Bed 3 Bedrooms
Wall. Rooms`
Int Bath
Model°Residential Floor Rooms 1 FUII + 1 H
Grade;Average Type Heat'Not Air Total Rooms'6 Rooms
--
http://issgl/intranet/Propdata/ParcelDetail.aspx?ID=17000 2/20`2007
Parcel Detail Page 2 of 3
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Stories 1 Story Heat Gas Found- Typical ��
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Y
Fuel _ - ,.... d1lon OwW
Permit History
issue P" Permit# d€r it Ire $ , atC'Imm
1/14/2003 Wood Deck 66394 $1,200 6/2/2004 12:00:00 AM
- Visit History,
}ate Who Pur,.'os
6/2/2004 12:00:00 AM Martin Flynn Drive by inspection only
7/15/2003 12:00:00 AM Paul Talbot Meas/Est
9/15/1999 12:00:00 AM Donna Dacey Meas/Listed
- Sales History
Lime Sale 'e Owner Bookipage Sale P.
1 9/15/1988 TORRES, CLEMENCIO & MARGARET TRS 6460/226
2 TORRES, CLEMENCIO B 2784/343
Assessment History
Save sl: yk""?>" Building Value F Value B V a IL!e Land Value Tot-al arcs
1 2007 $120,400 $2,400 $400 $525,400
2 2006 $111,300 $2,400 $400 $482,200
3 2005 $101,700 $2,300 $400 $429,600
4 2004 $81,900 $2,300 $400 $343,600
5 2003 $74,900 $2,300 $400 $165,400
6 2002 $74,900 $2,300 $400 $165,400
7 2001 $74,900 $2,300 $400 $165,400
8 2000 $60,000 $2,300 $0 $64,400
9 1999 $60,000 $2,300 $0 $64,400
10 1998 $60,000 $2,300 $0 $64,400
11 1997 $65,500 $0 $0 $82,900
_12 1996 $65,500 $0 $0 $82,900
13 1995 $65,500 $0 $0 $82,900 i
14 1994 $62,600 $0 $0 $74,600 f
http://issql/Intranet/propdata/ParcelDetail.aspx?ID=17000 2/20/2007
Parcel Detail �y r, Page 3 of 3
15 1993 $62,600 $0 $0 $74,600
16 1992 $71,100 $0 $0 $82,900
17 1991 $73,000 $0 $0 $101,300
18 1990 $73,000 $0 $0 $101,300
19 1989 $73,000 $0 $0 $101,300
20 1988 $56,600 $0 $0 $43,300
21 1987 $56,600 $0 $0 $43,300
22 1986 $56,600 $0 $0 $43,300
23 1985 $0 $0 $0 $0
Photos
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http://issql/intranet/Propdata/ParcelDetail.aspx?ID=17000 2/20/2007
Town of Barnstable
�Op THE raw
Regulatory Services
41 BAR ABLE, Thomas F. Geiler,Director
�A55 Public Health Division
Arfb MA'S a
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
May 4, 2007
Attn: Hyannis Fire
Health Inspector Meredith E. Morgan conducted a rental inspection in accordance with
Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary
Code, 105 CMR 410.482, the Health Department is required to notify the Fire
Department if there is a smoke detector violation, or possible smoke detector violation.
The following property had possible smoke detector(and\or CO detector)violation(s):
202 Seventh Ave. Assessors Map-Parcel: (245-080):
Smoke detectors on first and basement levels not operable. CO detector on first floor
next to two bedrooms not operable. House currently vacant.
MJred6b E. Morgan -Health Inspector
QAOrder letters\Housing viol ations\Rental ordinance\\Fire VlolationsTIRE TEMPLATE.doc
Certificate# 07 . 1406
Fee Paid: $130.00
Town of Barnstable
naaNSTArzLE'
p� i639. Regulatory Services Department
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
2008 CERTIFICATE of REGISTRATION
Property Location:202 Seventh Avenue Hyannis MA 02601-
Owner's Name: Torres. Clem & Margaret
Owner's Address 172 Harland Road Norwich CT 06360-
Owner's Representative's Name (If Applicable)
Address:
Telephone Number.:
Number of Rental Units On This Property 1 Number of Bedrooms Authorized: 3
Maximum Number of Motor Vehicles Authorized outside of Buildings Overnight: 4
Maximum Number of Occupants Authorized (occupants under 22 years of age are exempt) 5
7/8/2008 12/31/2008Q
Date Issued: Expiration Date Thomas A.McKean,R.S.Director of Public Health
*This certificate must be conspicuously posted within such dwelling or portion of dwelling*
�-
TM THE COMMONWEALTH OF MASSACHUSETTS
FORM 30 C&w HOBB$&WARREN
BOARD OF HEALTH
p►2�.s &-UN�
'CITY/TOWN
o DEPARTMENT
2.0 0 !�A A. 1 3'T -4*Is
ADDRESS
TELEPHONE
Address ZOZ 5;tV1t,-T I- w•k n►as_i._Occupant_. s & " A EAL 9-c%ala�-
Floor —"' Apartment No. 4o. of Occupants__
No. of Habitable Rooms(e No.Sleeping Rooms
No.dwelling or rooming units No.Stories
Name and address of owner G Cf.H f M40-e T To R.4fS
1 2 kAe- La V_QL Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
/ Containers:
V 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: \
Lighting:
STRUCTURE INT. Hall,Stairway:
0 st'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Su ply Line:
❑ MS ❑ ST P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRIC L Panels, Meters,Cir.:
❑ 110 IV220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
V ntil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1 , b
Bedroom 2
Bedroom 3 D
Bedroom 4
Hot Water Facil. Su Elect.:
acks, Flues,Ve ts,Sa ies:
Kitchen Facilities Sink 8`
Stove
Bathing,Toilet Fa ' . umb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted 0/V 0I4 OfAI
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIE F PERJU T
INSPECTOR TITLE {�4L-7H
DATE 7 Z/Q `/ TIME P•M
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
410.750: Conditions Deemed to Endanger orJm'pairIHealth 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 410:1500)(2)and 410.150(A)(3)or any
defect which renders them inoperable. 1
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing,heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents,cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
t .
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TOWN OF BARNSTABLE
LOCATION N2= n W - 1'1 ✓SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT - �0 v INSTALLER'S NAME&PHONE NO. C p
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER U- P�r►ne k1C,a7, Lh-✓r9-i
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
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THE COMMONWEALTH OF MASSACHUSETTS
` BOARD OF HEALTH
�{ ..................OF....... f ..................................
Appliration for Uigpma1 Workii Tonstrn.rtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (P<an Individual Sewage Disposal
stem at:
........ .---...Z.r' .....Avirr.�, ........&)_. 1Al .............................
............: _ (.�1 s S._...... ....... ......:.
Location- w or Lot No.
...
Owner �1 Address
Installer Address
UType of Building / Size Lot............................Sq. feet
Dwelling o. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4Other fixtures ------------------------------------------•---------•.--•----••----- ---...............•......................................
W Design Flow............................................gallons per person per day. Total daily flow: ..........................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth...____..._.....
x Disposal Trench-No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_.__---_________---_-.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 -------- .......f}
Description of Soil .11ei....... --�!;A !�----------------------------------••----------•------------------------------------.----------------
V ......_.....•-•---•-••----------••--------...•.................•------------•••-•----•-•---------••------•------------•----------•---------•--•-----•--------••------------.._..----•--------•-•--------•
� -------------------- --------------•-•••-----------•-------------------------------••-------•-•-•----------•••------
-----------
U Nature of Repairs or Alterations—Answer when applicable.__.�__�.. ... ............. ...• __. ---- �---
.............••••••------------•----------•-•••-----•••-•--•------••-•--------••-••-.....------.....•-------••••---------•-----••----•---••------••----------•--------•-• _1_......
Agreement: -
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issued y the bo d of heal
--. 7 .:.
n __ ... a &... Date
;Application Approved By......... •-•--- •. .......................................-............................. ---------•••......----------••--------•-
Date
'Application Disapproved for e f owing reasons---------------••-----------••---•-----------•----------•--------•---------------.....----•-----------••---•--•--
------------------••--....................•----•---------•--.......-•----•--------...........•---------••---------•--------------•••-•••-----------------••----•---•--•--•----•-----•------•------•.
° Date
PermitNo............................. ---------------- Issued.......................................................
i Date
PIP-
No._ ..--- - Fps.. •�!` .... ...._
"-- THE COMMONWEALTH OF.MASSACHUSETTS
BOARD OF HEALTH
t/ ..........OF........
�; 3 . - ' ...
Applitation for Bhip sal Workg Tomitrurtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: r
�i. >od
.... .,.? - ..4..... i i:�l <.�.. ` --------•-••--•--•-------•---=-•--.....-•----------------•-------....-•-------
Location-I d
s •� or Lot No.
,» Owner I
Addi-ess
a � . ... _ �� b 7. '._.gin-•--••-- -•-•..................................••_... .......--•------------••-•-•-•--..........
14 Installer Address
U. Type of Building Size Lot............................Sq. feet
�-, Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a
Other.—Type of Building •___________________________ No. of persons............................ Showers —
( ) Cafeteria ( )
d Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.............gallons Length................ Width................ Diameter____-..--_____-- Depth................
x Disposal Trench—No..................... Width.................... Total Length....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY........................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
...............
D Description of Soil.......,,� � r/ '
V ...........--••---•----------------•---••-•-----•--•--•---------...•---•---•-•-••--•••------•-••-•-•-•-----...-•----•-•-••-•--•----•-------•••---...--•---•-••------••--•-•--•-----•••-- --•--•------•.
W -------------- --------------------------------•-----------------------•----------•------------------• .......... s `
-!! -----------------------
U Nature of Repairs or Alterations—Answer when applicable_._f!g.. ��+,_g.'42---------_.__�_f�A�..,
-------------•--•-------------------------...•-----......••---...----------•-------------------------------•--------•-----:..-------------------•-•---••••--.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued.by the board of health.
_
/y
Date
Application Approved By--------- -------- _-•----
Date
Application Disapproved for e f" wing reasons---------------------•---------------•-------------------------------•-=--------•-••-••--•. -•-••------••....._
---------------------------------------------••------------------------------------------•-------••--
Date
PermitNo.............•-----...................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� �.. " F......i .......O / 1
.............................
(9rrifirate of Tnntphatrr ~F°
THI, 'A,,T CERTIFY, That the Inkl-ividual Sewage Disposal System constructed ( ) or Repaired
•• .-•----••••-•..............................
/I stiller :
_ ...................................................
has been, installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated------------------------.__.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................•----...---•------••------••--•-••----•-•---••-----.. Inspector........---•-------•--�---����'�-----}-•-- �.��£k
THE COMMONWEALTH OF MASSACHUSETTS
�..-- BOARD O HEALTH.
�4/ ............. ........
FEE..••......._<�-
-
�i��rn�ttl n��,� �nn,✓�tr�rtinn riattt .�M
Permission is hereby granted /63fa' ' �"� ,./' _•.__•' •-•--
to Construct or Repair (t.,�n Individual Sewage Disposal Systei
at No.: ......7Z
Street
as shown on the appl' tion r Disposal Works Construction ..................... Dated...........................
Board of Health
DATE- ..... ..--•---- ..........................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
AAt�
LT CATON SEWAGE PERMIT NO.
VILLAGE
lk
INSTALLER'S NA a ME & A_DDRESS
,S UILDER 0III L V%
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED r<'
11
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4 8 2'-1" 4'-8" 4 8 2'-1" I, , 4'-8"
- - —O � - - CLOSET. CUSTOM DOORS
/ TO BE DETERMINED
-�
N `COUNTER/DESK
N
2'f5" KAYAK RACK TO BE DETERMINED
c� NEW WINDOW 0 N N '
ao a0
N' r NEW VANITY/SINK N' r
REMOVE & I ch
REMOVE
STEP W '� ,®_ WAINSCOTING SURROUND
N cv 42" HIGH .
T
T
NEW FAN WITH — - -
HARDWOOD FLOORING
\ EXHAUST VENTING 8'-1"
T {j(
I NEW TOILET —�
- - NEW FRENCH DOORS
4-10' T-3' r 4'-10" 3'-3"
REMOVED *,
-- - ---- ,-:7z7-----CHANGING RAMP TO STEPS - -- -
OPTI
ON
IPROPOSED-EX ST'ING
GENERAL NOTES: .NOTE: DRAWING NUMBER:
A I-T SHED REMODEL FOR• s I. T DIMENSIONS SHOWN ARE FOR REFERENCE ONLY ° THE PLANS SHOWN ARE THE SOLE PROPERTY OF SCALE:
C .yw■ CAD
CONTRACTORIS I VER FYEXISTNG CONDITIONS THE DESIGNERANDCANNOT D,COPIED,��`) AND-DIMENSIONS IN THE FlELD PR10R TO START OF REPRODUCED AND/OR ALTERED,USED FOR PERMIT
rLEMBO REV I DENCE WORD AND/ORTOf EDMIf TIE ER,PARICK IMINCTRJmN 1/4�� 1
2,TPtE CENERAI CONTRAGTORSMALL BEAR SOLE AND/OPTONG WITHSIGNER,PATRI55 RIMINGTOM.
RE5PON51BIUTY FOR MEAN5 AND METHODS OF
• - CONSTRUCTION AND 5AFET'ON THE JOB SITE. -
_ ._„._ - - WORK SHALL CONFORM TO THE I-
292 7TH AVENUE 3. A"D (55i CHUSERS STATE BUILDING CODE ENTEST
[///��� COMMENCING
AND ALL OTHER APPLICABLE CODES.- Ann�OVe„1 f��filing
J ^YY lJ
APPLICABLE,CONTRACTOR SHALL IDENTIFY ALL DATE..
IXIS7ING LOAD BEARING ELEMENTS PRIOR TO
WEST HYANNISPORT�- MA _ .-_ _. _� .�_
WORK AND SHALL DESIGN AND PROVIDE .-
,_.. _.._.e....._...,,,,�-.,,;,_, __. _._�,....�-... ............... ._.....„,-.. SHORING AS REQUIRED TO SUPPORT LOADS DURING
P.O. BOX
Gt 10/15/201.8
f vO^ vOb 5O ANYI CIREPANCIES,ERROR5 AND/OR OM155ION5 P.dfiCk RIm In9tOn
MARSTONS MIU-5, MA IN THE NOTES,5HALL BE BROUGMT TO THE ATTENTION
- OF THE DESIGNER PRIOR TO COMMENCEMENT OF -
�L 7 CONSTRUCTION. PROCEEDING WITH CONSTRUCTION
508-2 V 0-/-7 O/4 CON5TITUTE5 ACCEPTANCE OF THE5E DOCUMENT5
- AND ANY D15CREPANCIE5,ERRORS AND/OR
- OMI55101,15 BECOME THE RE5PON51BIUTY OF THE -
BUILDING CONTRACTOR.
JI