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Home My WebLink About0006 SUNNY KNOLL DRIVE - Health - �' 6 Sonny'Knoll+D 'Hyannis'4:' . F , No. 4350 1/3 RED -!...,.f`,ia y!`t 'NF_t' FI'.�,.�••.1 S�(11.,•�.�. �'�t5.- �7:1.�.�:�� ✓��'� _ �: _._. �1 tc:. t' spy 10% � � `� � � � �� , Q �� J 10 i Miorandi, Donna From: Adam Meizinger[adam2312@gmail.com] Sent: Tuesday, May 05, 2015 8:40 AM To: Miorandi, Donna Subject: Bugs Donna, Regarding bedbugs at the house, The company/person I communicated with directly was PureHeat/Sandy. Sandy indicated to me in a text message after their inspection that there were no signs of bedbugs at the home. Sandy' s direct cell phone number is: +1 (508) 341- 3799. Please let me know if I can help any further. -Adam Sent from my iPhone i i i 1 s 1/22/2021 Citizen Web Request �. yno Citizen Request Management Request ID: 52376 Created: 4/30/2015 10:44:44 AM Status: Closed Assigned To: Miorandi, DonnaHealth Department Chapter 108 : Hazardous Anonymous: No Category: Materials Chapter II : Housing Substandard E.C. Date: 5/14/2015 Created By: Citizen Citations: Time Worked: 110.00 Response Time: 0.50 Request Location: 6 SUNNY IN1OLL DRIVE Hyannis, Ma 02601 Parcel Number: Map: 307 Block: 120 Lot: 000 Request: Donna Miorandi was called out on April 25 at 11:03 AM by Hyannis Fire.Lt. Robert Hennessey of Hy. Fire Dept. premises had been treated with Diatomaceous Earth (D.E.) which was all over the tables, floors, and house. Poision Control was called see recommendations in file. Also occupants were blind, old and in wheel chairs. Occupants were taken by a daughter until all the problems could be cleared. The house was condemned because of the conditions in house and electrical problem. Request Work History: Entered on 5/19/2015 8:20:21 AM House was re-inspected by wiring inspector, Robin Anderson, Patrick Franey and Donna Miorandi and allowed re-occupancy for this property. Patrick Franey, bldg.inspector, issued them an exit order for the shed that son was previously living in. Power was restored to house. Also, Deputy Dean Melanson was on site. Occupants were given smoke/co detectors by Hyannis fire Department. https:/fitsq ldb.tov.n.barnstabl e.ma.us/C itizenReq ues1M/Req uestPri ntPub.asp�QID=52376 1/1 1/22/2021 Citizen Web Request Ts1 C' MOO T.APLE] yBo, ' Citizen Request Management �w Request ID: 52376 Created: 4/30/2015 10:44:44 AM Status: Closed Assigned To: Miorandi, Donna Health Department Chapter 108 : Hazardous Anonymous: No Category: Materials Chapter II : Housing Substandard E.C. Date: 5/14/2015 Created By: Citizen Citations: Time Worked: 110.00 Response Time: 0.50 Request Location: 6 SUNNY KNOLL DRIVE 'Hyannis, Ma 02601 Parcel Number: Map: 307 Block: 120 Lot: 000 Request: Donna Miorandi was called out on April 25 at 11:03 AM by Hyannis Fire.Lt. Robert Hennessey of Hy. Fire Dept. premises had been treated with Diatomaceous Earth (D.E.)which was all over the tables, floors, and house. Poision Control was called see recommendations in file. Also occupants were blind, old and in wheel chairs. Occupants were taken by a daughter until all the problems could be cleared. The house was condemned because of the conditions in house and electrical problem. Request Work History: Entered on 5/19/2015 8:20:21 AM House was re-inspected by wiring inspector, Robin Anderson, Patrick Franey and Donna Miorandi and allowed re-occupancy for this property. Patrick Franey, bldg.inspector, issued them an exit order for the shed that son was previously living in. Power was restored to house. Also, Deputy Dean Melanson was on site. Occupants were given smoke/co detectors by Hyannis fire Department. https:/fitsq ldb.tovm.barnstabl e.ma.us/C itizenReq ues1M/Req uestPri ntPub.aspx?ID=52376 1/1 1/22/2021 Citizen Web Request s atus. y � Citizen Request Management Request ID: 47589 Created: 10/8/2013 10:21:13 AM Status: Closed Assigned To: O'Connell,TimothyHealth Department Anonymous: Yes Category: Chapter 54-5 : Rubbish and Garbage E.C. Date: 10/23/2013 Created By: Crocker, Sharon Citations: Health Department Time Worked: 1.00 Response Time: 4.00 Request Location: 6 SUNNY KNOLL DRNE Hyannis, Ma 02601 Parcel Number: Map: 307 Block: 120 Lot: 000 Request: Caller said the yard is a disaster. There is household trash which is picked from time to time, along with tons of other belongings. They also noted that the owners have a chicken coup attached to their house. They wondered if this was permitted. I explained chickens are allowed, and I was unaware of whether there was any regulations on whether the coup could be attached directly to house - would leave note for inspector. Request Work History: Entered on 10/15/2013 9:13:01 AM No enforceable garbage at property as of 10-11-13 http0/iitsq Idb.tovm.barnstable.ma.us/CitizenReq uest/WReq uestPri ntPub.asp)O.l D=47589 1/1 1/22/2021 Citizen Web Request i of 7. rd"e. 4VQ.S, l-0li�yv ,� .,•;4 Citizen Request Management Request ID: 33473 Created: 1/19/2011 2:59:11 PM Status: Closed Assigned To: Roma, Paul BuildingDept Anonymous: No Category: Code/Ordinance - Misc. E.C. Date: 2/9/2011 Created By: Shea, Sally Citations: BuildingDept Time Worked: 1.00 Response Time: 16.00 Request Location: 6 SUNNY KNOLL DRIVE Hyannis, Ma 02601 Parcel Number: Map: 307 Block: 120 Lot: 000 Request: 6 & 18 SUNNY KNOLL IS THE PROBLEM THE CALLER REPORTS. THERE IS A SHED THAT HAS BEEN PLACED AT 18 OR 6 AND IT IS TOO CLOSE TO THE PROPERTY LINE. THERE ARE HAMMOCKS (3 OR 4) HANGING FROM IT. THEY HAVE ADDED TO THE SHED. THERE HAVE 2-3 CARS ON THE PROPERTY. THE COMPLAINANT ASKS FOR A RETURN CALL. THEY ARE ALSO DIGGING POSTS IN THE GROUND. THE REASON THERE ARE 2 ADDRESSES IDENTIFIED IS BECAUSE THEY ARE RELATED AND THE PROBLEM IS ON BOTH ACCORDING TO THE CALLER, Request Work History: Entered on 2/4/2011 4:21:28 PM 2-4-11 site visit w/ photos; shed has no addition (aerial photos from 1960's show shed); play area needs no permit; posts in front need no permit and are not a structure. https:/ltsgIdb.town.barnstable.ma.us/CitizenReq uest/WRequestPrintPub.asp)C?ID=33473 1/1 r� � Memo from: Donna Z. Miorandi, R.S.-Health Inspector for Town of Barnstable Re: Incident at 6 Sunny Knoll Drive, Hyannis Date: April 26, 2015 On Saturday, April 25`h at 11: 03 am Hyannis Fire Department called Donna Miorandi, R.S., Health Inspector for the Town of Barnstable at home to respond to a"unique" incident at the.property of 6 Sunny Knoll Drive, Hyannis. Upon arrival DZM met with Lt. Robert Hennessey of the Hyannis Fire Department. Outside were two of the home's occupants, Tom Meizinger, Sr (elderly blind man) and his son, Tom Meizinger, Jr. Lt. Hennessey brought me up-to-date with what had occurred at this residence. Allegedly, a sister, Heidi Meizinger, who does not reside at this home had put down Diatomaceous Earth (D.E.) all over the inside of the house to get rid of a bed bug problem. This application was done the night of April 24th. It is assumed that she returned to her rental apartment located at 78 Linden St., Hyannis. Heidi's phone number is 508-648-7490. Tom Meizinger, Jr. had called the Barnstable Police Department, thinking that the application of D.E.might have been done by his sister maliciously. The Barnstable Police Department then called Hyannis Fire Department. Lt. Hennessey showed me the interior main floor of this ranch where the D.E. had obviously been applied throughout including the kitchen table. Inside the house were the other two occupants, Vicki Meizinger(owner), also blind and her new husband, Darryl Breffe, blind and in a wheelchair. It was noted that in the living room of this dwelling that Darryl Breffe is operating an internet radio station. Due to respiratory irritation we went back outside. Mr. Breffe was reluctant to leave because he did not want to shut down the radio station. Lt. Hennessey had earlier called Poison Control and their recommendation was to do the clean-up utilizing a HEPA vacuum and a N-95 mask. The family did not possess either of these pieces of equipment or the financial wherewithal to purchase them. As a result of this it was determined to have the son, Thomas Meizinger, Jr. (primary caretaker) call a professional company to have this done so it would be done properly and not exacerbate any health issues. Diatomaceous Earth is a respiratory irritant and with elderly and handicapped occupants in the home it was the best solution. The son called Oceanside Restoration 1-800-464-3318 and explained the situation and they were to call back. In the interim, the son had stated that his father, Tom Meizinger, Sr. (elderly and blind) was living in the basement. It was at this time that Lt. Hennessey and myself(DZM) entered the basement and found the bedroom where his father sleeps. It has no window and was loaded with much D.E. on the floor of this bedroom. While in the basement it was observed to have no smoke detector and much illegal, dangerous wiring. Due to this situation Lt. Hennessey then called for the Town's wiring inspector, Bill Amara, to respond to the property and also requested Lt. John Cosmo, Hyannis Fire Department. Now, we check all the bedrooms and it is determined that Tom Meizinger, Jr. "camps out" in the shed out back. We look at the shed that has become a bedroom with more illegal wiring connecting to the main house via the bulkhead. Inside the shedibedroom are two large dogs. The decision was made to call for a building inspector. Bill Amara, made the decision to have the electricity shut-off to the house. Therefore, Eversource (formerly NSAR) was called to the property to perform this job. Tom Perry, Building Commissioner, arrived on the scene and issued an exit order for the basement bedroom. Due to no electricity at the house the family cannot stay there and must temporarily relocate.- The Red Cross was called but family had called another sister, Lisa L. Meizinger, (774-521-8747) who resides in Mashpee for accommodations. It was determined that they would all go there. DZM left the scene at 1:15 pm and returned at 4 pm to check on the status of the situation. Upon my arrival I found Tom Meizinger, Jr. still outside the property with the 3 dogs, the rabbit and 3 chickens. During conversation with him he seemed determined to do the clean-up himself(against my advice) and that he was either going to the "Cuddle & Bubble"meaning the International Inn on Main St., Hyannis or he was going to tough it out with the animals and stay in the shed without electricity. He wanted to be able to feed and care for the animals and obviously the hotel wasn't going to take them in. He said the shed was all right to be in because it didn't have the D.E. in there and was not a respiratory threat. He was concerned about no electricity because that is "when the bugs come out in the dark". He also stated that since D.E. is sold in a hardware store on shelves for consumers to buy that it should be no problem for them to use and therefore in his mind was all right to do the clean-up. During this time his sister, Lisa Lee Meizinger, arrived in her vehicle with the three elderly blind occupants of the house. I asked her what she was doing and she stated she was returning for her father to use the bathroom and to retrieve their medications.At this time I left her with,information on the Lombard Fund and told her to make some calls. She then left the residence (with all 3 occupants) after saying goodbye to her brother Tom Meizinger, Jr. - At this time Tom Meizinger, Jr. informed me that Fowler& Sons had made an appointment to come to the house on Wednesday, April 29t'between 1- 3 pm. He also i I informed me that Oceanside Restoration had shown up to the property and gave him no quote for the clean-up to be done. In closing, as a point of information, Tom Meizinger, Jr. told me that Elder Services was involved with the family recently for a period of about a month and a half but that two weeks ago he let them go because he stated it was more work for him to watch over what they were doing and it was easier for him to be the primary caretaker. i Additional information: Phone number for this residence (landline) is 508-771-2312. Tom Meizinger, Jr. has a red truck outside on the property with the name "Specialized Services-Full Service Property Management" with a phone number-508-776-1019. I i HMIS PERM-GUAW Health 0 Pure DlatomaceousUrthProducts Flammability 0 MATERIAL SAFETY DATA SHEET Reactivity 0 Personal Protection E Date revised: 11/4/2011 1.CHEMICAL PRODUCT AND COMPANY IDENTIFICATION Trade Name(s): Perma-Guard Crawling Insect Control CAS: 61790-53-2 Generic Name:Natural Diatomaceous earth EINECS: 310-127-6 Chemical Name: Amorphous Silica Formula: SIO 2 Manufacturer: Perma-Guard, Inc. EPA Registration No. 73729-1-67197 Address: 625 East,2150 South Emergency: CHEMTREC-USA(800)424-9300 City: Bountiful State: UT Zip:84010 International: (703)527-3887(Collect) 2.COM.POSITION INFORMATION INGREDIENT Name: CAS Number: % PEL and TLV(except as noted) NATURAL DIATOMACEOUS EARTH(DE) 61790-53-2 100 Diatomaceous Earth AMORPHOUS SILICA (uncalcined) 6 mg/M'TOTAL DUST,MSHA 10 mg/M'TOTAL DUST,ACGIH 3. HAZARD IDENTIFICATION Summary:PROLONGED AND REPEATED EXPOSURE TO EXESSIVE CONCENTRATIONS OF THIS PRODUCT DUST,OR ANY NUISANCE DUST, CAN CAUSE CHRONIC PULMONARY DISEASE.DUST CONTACT WITH EYES MAY CAUSE TEMPORARY SCRATCHINESS OR REDNESS.THIS PRODUCT HAS NOT BEEN CLASSIFIED AS A CARCINOGEN BY NTP OR IARC. Medical Conditions which may be aggravated:PRE-EXISTING UPPER RESPIRATORY AND LUNG DISEASE SUCH AS. BUT NOT LIMITED TO BRONCHITIS,EMPHYSEMA AND ASTHMA. Target Organ(s):LUNGS,EYES Acute health Effects: TRANSITORY UPPER RESPIRATORY OR EYE IRRITATION. Chronic Health Effects:PROLONGED AND REPEATED EXPOSURES TO EXCESSIVE CONCENTRATIONS OF PRODUCT DUST, IN EXCESS OF THE PEL/rLV,CAN CAUSE CHRONIC PULMONARY DISEASE. Primary Entry Route(s): INHALATION,DUST CONTACT WITH EYES. Inhalation:IRRITATION AND SORENESS IN THROAT&NOSE.IN EXTREME EXPOSURES SOME CONGESTION MAY OCCUR, Eyes:TEMPORARY IRRITATION OR INFAMMATION. Skin Contact:NA Skin Absorption: NA Ingestion:NOT HAZARDOUS WHEN INGESTED 4. FIRST AID MEASURES Inhalation: REMOVE TO FRESH AIR.DRINK WATER TO CLEAR THROAT AND BLOW NOSE TO EVACUATE DUST. Eyes:FLUSH EYES WITH LARGE QUANTITIES OF WATER.IF IRRITATION PERSISTS CONSULT A PHYSICIAN. Skin Contact: NA Skin Absorption:NA Ingestion: NOT HAZARDOUS WHEN INGESTED 5. FIRE FIGHTING MEASURES Flash Point:(Method):NON FLAMMABLE NFPA Flammable/Combustible Liquid Classification:NA Flammable Limits:LEL:NA UEL:NA Auto-Ignition Temperature:NA Extinguishing Media:NA Unusual Fire or Explosive Hazards:NONE Special Fire-Fighting Procedures:NONE 6. ACCIDENTAL RELEASE MEASURES Procedures for Spill/Leak:VACUUM/CLEAN DUST WITH EQUIPMENT FITTED WITH A HEPA FILTER.USE A DUST SUPPRESSANT SUCH AS WATER IF SWEEPING IS NECESSARY. 7. HANDLING AND STORAGE Minimize Dust generation and accumulation. Avoid Breathing Dust. Avoid contact with eyes. Seal broken bags immediately. Continue to follow all MSDS label warnings when handling empty containers. J Perma-Guard Crawling Insect Control MSDS FOR DISTRIBUTION IN THE USA ONLY rev. 11/4/2011 Pg.2 8. EXPOSURE CONTROLS/PERSONAL PROTECTION Goggles:GOGGLES OR SAFETY GLASSES WITH SIDE-SHIELDS ARE RECOMMENDED. Gloves:NOT NORMALLY REQUIRED. Respirator:<IOX PEL, USE AN N95 QUARTER OR HALF MASK RESPIRATOR.<50X PEL,USE A FUILL FACE RES- PIRATOR EQUIPPED WITH N95 FILTERS.<20OX PEL,USE A POWERED AIR PURIFYING RESPIRATOR(POSITIVE PRESSURE)WITH N95 FILTERS.>20OX PEL,USE A FULL FACE TYPE C SUPPLIED AIR RESPIRATOR (CONTINUOUS FLOW MODE). Ventilation:USE SUFFICIENT NATURAL OR MECHANICAL VENTILATION TO KEEP DUST LEVEL BELOW PEL. Other: Special considerations for repair/maintenance of contaminated equipment:INSURE PROPER RESPIRATORY PROTECTION. 9. PHYSICAL AND CHEMICAL PROPERTIES Appearance and odor: FINE WHITE POWDER,NO ODOR Boiling Point: NA Evaporation Rate: ( =1): NA Specific Gravity(water=1) : 2.2 Vapor Pressure: NA Melting Point: ND %Volatile by Volume: NIL Water Solubility: Negligible Vapor Density: NA pH: 7.5-9.0 10. STABILITY and REACTIVITY MATERIAL IS STABLE. HAZARDOUS POLYMERIZATION CANNOT OCCUR. Chemical Incompatibilities: HYDROFLUORIC ACID. Conditions to Avoid: NONE IN DESIGNED USE. 11.TOXICOLOGICAL INFORMATION Summary: PROLONGED AND REPEATED EXPOSURE TO EXESSIVE CONCENTRATIONS OF THIS PRODUCT'S DUST,OR ANY NUISANCE DUST, CAN CAUSE CHRONIC PULMONARY DISEASE. DUST CONTACT WITH EYES MAY CAUSE TEMPORARY SCRATCHINESS OR REDNESS.THIS PRODUCT HAS NOT BEEN CLASSIFIED AS A CARCINOGEN BY THE NTP OR IARC. 12. ECOLOGICAL INFORMATION GENERALLY CONSIDERED CHEMICALLY INERT IN THE ENVIRONMENT. USED MATERIAL WHICH HAS BECOME CONTAMINATED MAY HAVE SIGNIFICANTLY DIFFERENT CHARACTERISTICS BASED ON THE CONTAMINANTS AND SHOULD BE EVALUATED ACCORDINGLY. 13.DISPOSAL CONSIDERATIONS WASTE IS NOT HAZARDOUS AS DEFINED BY RCRA(40 CFR261).OTHER STATE AND LOCAL REGU- LATIONS MAY VARY. CONSULT LOCAL AGENCIES AS NEEDED.USED MATERIAL WHICH HAS BE- COME CONTAMINATED MAY HAVE SIGNIFICANTLY DIFFERENT CHARACTERISTICS BASED ON THE CONTAMINANTS AND SHOULD BE EVALUATED ACCORDINGLY 14.TRANSPORTATION INFORMATION D.O.T. proper shipping name: EARTH,DIATOMACEOUS,CRUDE OR GROUND.Hazard Classification: NOT CLASSIFIED Reportable Quantities:NOT APPLICABLE UN(United Nations),NA(North America)Number: NA 15. REGULATORY INFORMATION OSHA:Hazard Communications Standard 29CFR 1910.1200:MATERIAL IS CONSIDERED HAZARDOUS.SEE SECTION 3 RCRA:THE MATERIAL IS NOT DEFINED AS HAZARDOUS WASTE 40 CFR 261. TSCA:THIS MATERIAL IS LISTED IN THE TSCA INVENTORY,AND IS NOT OTHERWISE REGULATED BY TSCA SEC 4,5,6,7,OR 12. CRCLA:MATERIAL IS NOT REPORTABLE UNDER CERCLA.LOCAL REQUIREMENTS MAY VARY. SARA:311/312 HAZARD CATEGORIES—IMMEDIATE AND DELAYED HEALTH, 313 REPORTABLE INGREDIENTS-NONE. Canada:THIS PRODUCT IS LISTED ON THE DSL. California Proposition 65: NOT APPLICABLE. 16.OTHER INFORMATION Storage Segregation Hazard Classes:NA Special Handling/Storage: REPAIR ALL BROKEN BAGS IMMEDIATELY Special Workplace Engineering Controls:ADEQUATE VENTILATION TO KEEP DUST LEVEL BELOW PEL. PREPARED/REVISED BY:Marvin Haney,Penna-Guard,Inc.(801)295-2025 As of the date ofthis document,the foregoing information is believed to be accurate and is provided in good faith to comply with appropriate federal and state Iaw(s).However,no warranty or representation with respect to such information is intended or given. /J ♦ if, Dr to ta tnaceo&&q a)t t 0 •� 100% Pure Freshwater D(atomaceous Earth Mixing Rato-AB an anti-wking agont to C�M. R Ino mixcd in animal fe ds In an amountnot to c=ocd 20A by weight of total ration fit, PW R I tlM Qmaceous lti Eom ol?T03 and How-tb VWW 0 ISM 67061 0 LBS MADE 114 USA •Alc:h t/i foot!CJ+er"lC3 Ctw 6f O S� i�s's %. i a i _i r Rpm MATERIAL r _ ALA � c a np EPA had idt R�1P Rrtd W470 No a tc;im!psts ki re-,U Ei RAP refassrlo con i xo tea P do to(PA MATERIAL IL SSA 4 ' �'� �fd�► J..1 ti.� 4yk �r l' .,- �, ; �� .; , .ts � .- � r3'� ✓ / � r�! _ � 9�',� ! � �� ?1 �� .. �� f �� `��i �� A - .. .i� � �?l� r• Y;• r. .��- � . . `'. 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BUILDER OR OWNER DATE PERMIT ISSUED . DATE COMPLIANCE ISSUED �.� _ i� . . _ 'c I — r .,. , �� t � I o � � n �, � it cv d FE:B .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................0 F.......................................................................................... Appliration for Bi-4paiial Workii Tontitrurtion an it Application is hereby -made for a Permit to Construct (Y) or Repair an Individual Sewage Disposal System at: SY.Al./L")/ ..... .......................... ......... ................................. .............................................................. ..... ..... ....... ocation-Address A ......... 41 .......... ........ ................ .......... ..... ............................. ......... . Owner7 O 1/1 dres� .......................... ........I............. ...... !` .. 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 Pa Other fixtures ..................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid'capacity............gallons Length................ Width-_____-___---___ Diameter.-._-___-_____._ Depth_..._..._....... Disposal Trench—No..................... Width..........._........ Total Length..__.._._._.....____ Total leaching area....................sq. f t. Seepage Pit No..................... Diameter.._._........_...... Depth below inlet.................._. Total leaching area:.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) - Percolation Test Results Per-formed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit............_....... Depth to ground water-_._-________-_-._...... Test Pit No. 2................minutes per inch Depth of Test Pit___..___.._._....... Depth to ground water......._.............__. 0 / ...Y-/o J—!!::-----pvc,0W----------------------------- Description of Soil./� P j q....................DWI ............................. .................................................................................... U ......................................................................................................................................................................................................... .......................... ............................................................................................................................................................................. 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 TLILHE 5 of the State Sanitary Code V undersigned further agrees not to place the system in operation until a Certificate of Compliance has be is e 6 #A b d f health. Si ed - .............=� ... . . ........... ................................................. ................................ Date, ApplicationApproved By..... .......... .... .... . . ... .. .. ..... ....t............................ ........ Date Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued_../ ........ . .................. Date o No. 7 _" Flcs...... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F.............................................------....................................... ApplirFation for UiiposFal Works Tonstratrtion "motif Application is hereby made for a Permit to Construct ()6 or Repair ( ) an Individual Sewage Disposal systemat- .f.... -- -------------------- ---- . , Lo ation-Address .. e. ...... il ... .- U/�! / :: 4�-� .............................../ _.... Owner ddress a ci r S �..�a�/ �, .................... � ..................... ••••••..3' ......-Q/. �' .--- ---- Installer Address QType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( )_ Garbage Grinder ( ) p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QI 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........................................ aTest Pit. No. 1................minutes per inch Depth of Test Pit.--......:.......... Depth to ground water..........--............ (% Test Pit No. 2................minutes per inch Depth of Test Pit............----.... Depth to ground water..-----................. - a.�--- - iv)w&/---------------------------- Description of Soil-�-- ------•--- -.............................................................. ----------------------------------------------------------- --------------------------------- ....................................... U •-••-•-•-•-••••----•--•••-••-•••••-•-•••••••••--•--•-•-•-•••-•••--•--•-•-••••-•-••--=----------••••••-•--•-----••-••••-•-----•---•--•-•-•-••••-••--•••••----•---•-•-•••--•---------•-•-••-•----•-••••••- ----------------•----------------------------------------------------------------------•--------•-----------------....--------------------•----------------------------------------•--•--•••--•-•-•-•-•- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•---•--•----•---•------------------•--------------------.........-----------•---••----------------------- ------------------------ .......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f'tT/'1'•-� the provisions of Ll-TL' 5 of the State Sanitary C de ` T undersigned further agrees not to place the system in operation until a Certificate of Compliance has be is ed b - of health. Sied. ......••••-• ..........................•. ••-•----... ...........•---•- Datee Application Approved By...... _.......... ......• ` Date Application Disapproved'for the following reasons:.......................•------------------------------------------------------------------•-••••............... Date PermitNo-,..................................................... Issued....................................................... Date '1r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t Z> ..............OF..........dG:l..�i!lll'X . .as1�4G ^'Y`"..............-..........-... Totif iratr of Tontplianrr TH IS, � C TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired b1 I ..................... ..........................._ ......................... y ...^... -••--•- !% I staller , GliYi�J has been installed in accordance with the provisions of '' 5 of The State Sanitary Codei;tscribe in the application for Disposal Works Construction Permit No................Tye'.'............ dated._/.A..��1�•.,��............ 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 FEE.... ................. i os�a1`- or fon ion rrntit Permission is herebyrante (............�' -.----••--• . g to Cons�uct ( )�epair ( ) an Individual Sew a isponyst / at No....-•.,P) c--- � ` ............. reet t as shown on the application for Disposal Works Construction -PeJrmi*it�.�........o-..�'---- - D. to. .d...�. ...f.:.�.�. -------•-•- ' Board o-f Hea th. .-•---------. DATE..../..'2...... --------•------------- ................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .,�,,.�^? .•