HomeMy WebLinkAbout0007 STEVENS STREET UNIT UNIT 1 - Health Stevens Street
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"` Hna•. CERTIFICATE OF ANALYSIS Page: 1
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 5/30/2007
Manuel Roderick
Roderick Construction Order No.: G0740530
P O Box 370 -
Marstons Mills, MA 02648
Laboratory ID#: 0740530-01 Description: Water-New Main
Sample#: 22 Sampling Location: Stevens St.Condos Hyannis,MA Collected: 5/22/2007
Collected by: M.Roderick EOL Received: 5/22/2007
Test Parameters
ITEM RESULT UNITS RL MCL Method# Tested
Total Coliform 0 CFU/IOOmL 0 0 MF-SM 9222E 5/22/2007
Laboratory ID#: 0740530-02 Description: Water-New Main
Sample#: 20 Sampling Location: Stevens St.Condos Hyannis,MA Collected: 5/22/2007
Collected by: M.Roderick FS Received: 5/22/2007
Test Parameters
ITEM RESULT UNITS RL MCL Method# - Tested
Total Coliform 0 CFU/I OOmL 0 0 MF-SM 9222E 5/2:�2P07 —;-
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— ._:—_ ------._.--- -------- —_------C-------�--- ...-......_.:
Laboratory ID#
0740530-03 Description: Water-New Main
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Sample#: 21 Sampling Location: Stevens St.Condos Hyannis,MA Collected: 5/2V3007
Collected by: M.Roderick 6'.'.Spur-, Received^. 5/22-72007
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Test Parameters w co
ITEM RESULT UNITS RL MCL Method# TT stied m
Total Coliform 0 CFU/IOOmL 0 0 MF-SM 9222E 5/22/2007
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REPORT 00
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SCANNED
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ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
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Certified Fee
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O Return Receipt Fee Here O
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PS Form 3800,August 2006(Reveise)PSN 7530-02-000.9047
COMPLETE •N iiii COMPLETE THIS SECTIONON DELIVERY
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(Transfer from service laben 7007 2680 0002 001 01 7 311
Ps Form 3811,February 2004 Domestic Return Receipt 102595-02 M-1540
UNITED STif ; Ti�t� }✓tG�:_. krstless`tVt ," .�
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Town of Barnstable
Health Division
200 Main Street
II Hyannis,MA'02601
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Town of Barnstable Barnstable
Regulatory Services Department �'edcaC j
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IIARNS"CAULE,
"Asp �°' Public Health Division
qj 039. �0
Arf0 M 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
September 9, 2008
CERTIFIED MAIL 7007 2680 0002 6701 7311
Steven Winter trust
277 Bay Lane
Centerville, Ma 02632
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE Il—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 7 D Stevens Street,Hyannis was inspected
on September 9, 2008,by Jaime Cabot, Health Inspector for the Town of Barnstable.
This inspection was conducted on the basis of the rental registration in accordance with
Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements:
Flooding and signs of water damage were observed in basement. A small hole and
cracked plaster were observed in the basement.
105 CMR 410.5527 Screens for doors: No screen or storm door was provided for the
front entry.
You are directed to correct the violations listed above within thirty(30) days of
your receipt of this notice.
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.
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 BOARD OF HEALTH /
Thomas A. McKean, R.S., CHO
Director of Public Health -7 C_
Town of Barnstable
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' HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
FORM 30 C&W
BOARD OF HEALTH
A,V_t4 `ca A b I'c
CITY/TOWN
0
DEPARTMENT
�� ADDRESS 6 Z „!
GSM 5V0y`oW �S2
TEL PHON
Address TI[VeNc.. QT. N�Ae�1��S Occupant
Floor Apartment No.__ —No.of Occupants__
No.of Habitable Rooms—No.Sleeping Rooms Z_
No.dwelling or rooming unitsSr No.Stories_2
Name and addre�yS�off wner � TwN t..a► N1CA-L T20&1
YCJ X %1 0 SUILV I LLIL, t`AA OZ(o3 Z Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches: 111j v slco e am ►.j
Dual Egress: and Obst'n.: 000e, Z W C45�
❑ B ❑ F ❑ M Doors,Windows: 1-
Roof
Gutters, Drains:
Walls.-
Foundation:
Chimney: G
BASEMENT Gen.Sanitation: V_, -t 6. ' ! bZ00
Dampness: fZ I..!A 'S L►
Stairs: AS.L.
Li htin : (>�
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling: ►t.'
Hall Lighting: C ,,,A- v -tN 0w-%4 A 10 LOV
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box.-
Gen. Basem6nt 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. Elect.:
Stacks, Flues,Vents,
Kitchen Facilities Sink
0
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 QcAeAac-f-i �' eLc-S sV7q'�I
Locks on Doors: O ti 94f.h I S
® ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES F PERJURY " 'J
INSPECTOR TITLE �i�A�-�� �ti S ?
DATE TIME / /,'00 P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION � P.M.
.'.'
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises,shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 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
L410.150(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.
FORM 30
I- W Ho8Rs8 ARREN M THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 roli 4--.1
CITY/TOWN
a DEPARTMENT
ADDRESS
TELEPHONE —!
Address _ �9`. ,4% k Occupant- i e� >G
Floor -Apartment No. -- . No. of Occupants___ t—tr.�-�'
No. of Habitable Rooms_, __No.Sleeping Rooms_-__ _
No.dwelling or rooming units_—_—_ _ No.Stories
-- Name and add rees/s.of owner r� Ay+ P14� rt,�t'L— ?��J
� f �" 'Y .�.',�1�/�.l /• f 'l - _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 OF ❑ M Doors,Windows:
Roof 414 11KI /_.Ve`a 6W 44/!:r 2�'G.1
Gutters, Dr ins:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs: icy r a
Li htin : _6;jj�,14
STRUCTURE INT. a�-St iA- ' �� '�,g. , " t,//r
Hall, Floor,Wall,Ceiling:
Hall Lighting: / ) r ze ly/o r_'6'/
..Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N E ui . Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:9 i t /v z. . ,' ' T 1�% q• / Gr
ElMS ❑ ST ElP Waste Lin ,, 'i i ,p
H.W.Tanks Safety and Vents 6� Q_? � � l.,IA
ELECTRICAL Panels,, fuleter�,,.Cir.: ,� ' (,!
❑ 110 ❑ 220 FusinR--Grnd./_1 , /t f
AMP: Gen:Cgnd.-D.istrib-.Box' `x d
Cas.n Baser�.ePI V�/irin --,�S //�. o s� r rTi d r JlJ
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom(1).
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin, Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Bu I Idi ng Posted TV F_y"e /l
Locks on Doors: iy- -
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY." 1.
INSPECTORf'° < '9TITLE �' i �i
DATE `" "'C`-7'� TIME _ P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION + P.M.
4
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shali be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category,in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
06
LOCATI SEWAGE PERMIT NO.
VILLAGE
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INSTA LLER'S NAME i ADDRESS
UILD R OR OWNER
�S a
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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TH= COMIv104N. EALTH OF MASSACHUSETTS
t-211106k BOAR® OF HEALTH
......O F.................I..".,....I.........
Appliration for Disposal Works Tomitratrtinat Prrutit
Applicatipnhereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: .pt- let
• • = '
ocation-Address j- - or Lot No.
r
o ner Address
U
a ------------
--------
-........
-------
•- --------.-. Address ��-•------. ---------
a/ller
QType of Building j� Size Lot___: .—� .........Sq. feet
V Dwelling—No. of Bedrooms......_.t.................. .. .....Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ............................ --------------------------
Design Flow.......g.. ..........................gallons per person per d - . Total daily flow... �� d Ions.
W F.. �iy v lr � . �F �� rr c� gal
�,� _ Ar
WSeptic Tank—Liquid capacity_. _AP..gallons Length............... Width_$:........... Diameter__.____-_-_____- Depth..,5.........
x Disposal Trench--No..................... Width.........4.......... Total Length................. .. Total leaching area....................sq. ft.
Seepage Pit No..... ........... Diameter....__E .�l-_.-__ Depth below inlet...... :... Total leaching area•_-`3A?...sq. ft.
z Other Distribution box Dosing to k ( )
Percolation Test Results Performed b ..........,r! ...-........................... Date.. r .._ _. �
y.. , ,
Test Pit No. 1 ._..minutes per inch Depth of Test Pit-----�.2:_,l.... Depth to ground wa r.._....
(i Test Pit No. 2__L;.-.....minutes per inch Depth of Test Pit---- Depth to ground water-______
-•.........................•-••----- -•-••-••-•...-•-•-•••-•--•--••-------••--.:.........._...........•-----•-----------•-----••-•--..............•-•---t�.�-e-�
Description of Soil......Q..---.J0.... ----- .1 �P �� �r
W ••--•--•-•-•---------------------•-•-••-----•••••-•-•----•-•-------••-----._..__._._.._..•-------••---•--------•-•...------•-••----•--•---••-•••--•---------••-------••---•......-------••----••-•-•.--
UNature of Repairs or Alterations—Answer hen applicable...............................................................................................
~ �` 'tis _j......,,Zatt_-----•--------••--•------------------------------------------•------------•-------------------------------.._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TiTI.I 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued by the jk\and of health.
Signed .
Dat
Application Approved By........ e- c..... 1 ..------•--....--•-•---•--- ....... d°- � �/°---------
at
ate
Application Disapproved for the following reasons--------------------------------------------•-----------------------------------------------------.......
-----------------------------•-••--.--•--••-•--•----••••-----.....-•------•---•----•----.......----•--•--
PermitNo...............................................".......... Issued...........................................Date Date......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH \®�
..........................................OF.....................................................................................
TOrrtifirFatr of Tnranph aatrr
THIS IS TO CERTIFY, hat the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer P•
at....:. ..._........�� - !'Pi.rr. \'�`... = - i'.......c.-•..• -------------•------------------•--------...........................................
has been installed in accordance with the provi ' ris of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ .6/ -. 5.t6_)..._--___-___- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................•--•------.......-•-•---•---.............•-•..---_.. Inspector....................................................................................
NO*� � �`.-..« FEB............................_
T14E COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................O F..........................................--•--------------...............................
Aliptirativa,for 3liapos al Works Tomi�union amit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
• .............».......................................................................... ..........--......................................................................................
Owner Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
QI Other fixtures ................................. .
WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal
Pit Trench
o.- _No. .......•Di......id h�:_- ....D Total Length.............:.}. .. Total leaching area....................sq. ft.
Seepage epth below inlet......��_. Tx... Total leaching area..-� ....sq. ft.
Z Other Distribution box ( Dosing t k ( ) ��
j Date...:: / 4j
Percolation Test Results Performed by_...._... •
4A �; O
,--a Test Pit No. 1................minutes per inch Depth of Test Pit.... � _ Depth to ground w r...._. �''
Test Pit No. 2.. + ►_.....minutes per inch Depth of Test Pit... ... Depth to ground water------- le
.a !_
.................................................. ---
O Description of Soil - CIS". l �� 0.... sCd/.
U ............. .._. G�4►9h �2 c s�G .-••1�--! • ,�"' . .................................
W --.......................-.......................................--------•--.......----------••------•-------------------------------•-•------•---...---•--...--•------------------------------------•
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
.......................... ----------------------•-•-----------•----•------------•--...........----------------------------------•--•--------•-------•-----•---------------•--••--•---••-•--•-•-_.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITT.i^, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ued by the oard of health.
Signed.
.?..........:r.. ..... .. ........ -------------------
Application Approved BY-----... ....................... -- ...........
ate
Application Disapproved for the following reasons:-----••---------------------•----------------------------------------------------------------- --------•--••.
•-••------------------------------•----------•--......---......-----•-----....._...............----•-----'-------.....--•--------------=------------------------•-------...-----•----------•---------••--
Date
Permit No......................................................... Issued-....................................
...................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(1.01rdifirate of Tootph aurr
THIS IS TO CERTIFY, That the'j.ndividual Sewage Disposal System constructed ( ) or Repaired ( )
by------------------------------------------------------------ ........ .........................................................
Installer
has been installed in accordance with the P ro-v satins of TI i E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. s __.).Sdl .............. dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
516 OF.....................................................................................
io oo 1 rds! Toato#r iou troth
Permission is herebyranted------------------------------- -----•-----------•------------ ...---------------------•......
g �
to Constr ct i7?
or Re air ( ) an Individual Sewa a Disposal System
----------------•-----------•--------•--•----•--
Street
as shown on the application for Disposal Works Construction Permit No.................... Daped.._....__....__.....__....................
-ri,.��• � ,rj;,, ---------------• ------
///�, Board ea_V
DATE. Gl.-.-.. ............................
y�F5(RM 1255 HOBBS & WARREN, INC., PUBLISHERS
�
------------.OF.----------''-'-'---'-------- �
563
NCq�2............. Fimx.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............................OF.........................................................................................
Appliration for Disputittl Works Tongtrnrtiun 11amit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................__.............................................................................. ----...-----...-•--............----•-.........----•----......--------------------...-----------•--
Location-Address or Lot No.
j ......................__....................................•••--••--•....................._...• -•--...•---•--•---•-•••-•------...................................................................
Owner Address
W ...---•----•--....----••-•.......................................... .......•--••••••••••--•---••----......---.._..................__..................................
1.4 Installer Address
� Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
G" 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.......................................
04 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ...........•---- .............................................................................................................••----......--•-•-•.------
ODescription of Soil...............................................................................................................................
W -------•-•---------------- ------------•---•----•-----•----.........................................................----------•-------...............................................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
--------•-------------------•-----•--------------•---------•---•--•-------------------------........•--••-•••••---•--- •-------------•••----•••-----••------•---•-----•-•---•......•---••-•-•--....-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITTLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... .................................
* Dat
Application Approved BY .......' '......`'�'rf/% % f /I - .............
' Date
Application Disapproved for the following reasons:
....................... -----------._
--•--•--------•--•--•--------------------------------•-•------------•-------------------•--•------------...-----•-•--•---•-------•------•--------------------------•---------------------------------•---
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................I.....................OF...................................................................................
Tntifirtttr of ff amplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....................................................................................................................................................................................................
Installer
at...........................................................................................-----------------------•--------•-----------------•--•----------------------•-------------•--•----------
has been installed in accordance with the provisions of TI 'LF. >pf The State Sanitary Code as described in the
application for Disposal Works Construction Permit No g', _--__-_G-.,.3�................. ` dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................•---......--•-----•-......._----•------•---..._....._ Inspector....................................................................................
THE COMMONWEALTH OF,MASSACHUSETTS
BOARD OF HEALTH .
/,
UWposn1 Works Tnndr inn rrmft
Permissionhereby granted...............................................................................................................................................
to Construct ) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No._._..........�._....__ Dated..........................................
DATE..................................///�/&...................
a of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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