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0023 UNCLE WILLIES WAY - Health
23 Uncle Willies Way Hyannis P A 292 308 A r r r Y ' �pFIKE TaJy� A Barnstable y�P Town`�o TBarnstable ' *AnieacaCdO IIA LE.MASS. � .Board of Health y nnss . _ a6gq. �0 • '_ �ArFO MA1 a' 200`Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 _ Paul Canniff,D.M.D. F ' Junichi Sawayanagi '. March 23, 2010 F Mr. Luciano De°Jesus Ramos 23 Uncle Willlies Way Hyannis, MA 02601 'Dear Mr. Ramos, Recently the Town of Barnstable Public Health'Division received a complaint relative to a storage trailer located at 23 Uncle Willies'Way, Hyannis. The Public Health Division requests that you contact Cynthia Martin of this office, at 508-862-4645,to schedule an appointment to discuss the use of the trailer and to inspect• y its,contents. The purpose.6f this inspection is1,to verify that that the trailer is not being used for the,improper storage of hazardous material. • Sincerely yours: —Mr. hom"s McKean, Director of Public Health Aa- YA -7 rk ot ; . _417— i L : 1 l J' , y a µ4�i fd� 7f gg `� ;4' ray+'r.T 'r '# .`;. 1a5Oz:. d� ay` � -'�iJy° a 4J 111 t ;i tug RrN r ''tea t !� P{i �at ter» �� ��„�; �^ fr r 4., � � � � r, „' .%r,•y., .ft 2`rA v e I. a r< � K,� /? "•. ,� .. '7 ,1`� � � \`;a. ,.+�! � .� .rid' -- '� c.. � •, - t 5 jr C01. -, y i3 -��o Town of Barnstable ¢ SHE TQ� o Regulatory Services IIARxSTABLE. Thomas F..Geiler,Director y MASS. 1639. Public Health Division Ar fA MA'S A" . Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 26, 2009 Attn: Hyannis Fire i On June 25, 2009 Health Inspector Donald Desmarais RS conducted a housing complaint investigation. The.State Department"of Public Health has not promulgated regulations for CO detectors into 105 CMR 410.000 the State Housing Code to date. It is the policy of the Town of Barnstable Health Division to take similar actions for CO detector violations as is currently required for smoke. detector violations (under 105 CMR 410.482), which is to notify the Fire Department if there is a violation, or possible- violation observed. The following property had possible CO and smoke detector violations: 23 Uncle Willys Way, Hyannis,. Assessors Map-Parcel: (292-308): -No CO detectors present at property. No smokes at property. Donald Desmarais RS, H alth nspucer Q:\Order letters\Housing violations\Rental ordinance\\Fire Violations\CO TEMPCATE.doc °F1"ETA, Town of Barnstable s,AB Regulatory Services r� MASS.9. �m� Thomas F. Geiler, Director QED MA'S A , Public Health Division Thomas McKean, Director . 200.Main Streets Hyannis, MA 02601 MINOR MI -0- ; ram : DATE: I 1 Z 3 /6 f NUMBER OF PAGES TO FOLLOW: 2Z j .. .r TO: I FROM: CA *k 12 EC--to� PHON PHONE: i k0b) 7 7 1 B0 ,6 C� (508)862-4644 . FAX LONE:08 FAX PHONE: (508)790-6304 cc: S NOTES/COMMENTS: y�•V�-5t QAFax Form.doc Y Certified Mail#7006 0810 0000 3524 8844 �OFTNE r0{y� Town of Barnstable Regulatory Services i*9 BARNSTABLE, 0 "ASS. Thomas F. Geiler, Director O i639. ArF°M Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 13, 2007 Ron Coelho 23 Uncle Willie's Way Hyannis, MA 02601 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 23 Uncle Willie's Way Hyannis, was inspected on March 8, 2007 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint received by the Town of Barnstable. The following violations of the State Sanitary Code were observed: 105 CMR 410.482 — Smoke Detectors.No smoke detectors observed within home. 105 CMR 410.300 & 310 CMR 15.00—Sanitary Drainage System Required. Observed six bedrooms within home when septic (permit# 82-73) capacity is only for three bedrooms. The following violations of the Town of Barnstable Code were observed: 170-4—Certificate of Registration. Rental property is not registered with Town of Barnstable Health Department. Prohibition. Observed seven cars parked at home overnight when only four are allowed. QAOrder letters\Housing violations\23 Uncle Willie's Way.doc You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by installing smoke detectors in accordance with Mass Fire Codes. You are directed to correct the violations listed above within fourteen (14) days of your receipt of this notice by either upgrading septic system to accommodate for extra bedrooms or by removing bedrooms (this must be done by removing mattresses and bedroom door and making opening into room 5' wide); and by removing mattresses in basement and door to basement and making the opening 5' wide. 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 $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Timothy O'Connell, Health Inspector QAOrder letters\Housing violations\23 Uncle Willie's Way.doc Certified Mail#7006 0810 0000 3524 8844 4pFz tati Town of Barnstable M .Regulatory- Services * tl BARN$'rABLE, + RAs$. Thomas F. Geiler,Director �p s6g9• �� _ Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 13, 2007 Ron Coelho 23 Uncle Willie's Way Hyannis, MA 02601 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 of 23 Uncle-Willie's' Way Hyannis, was inspected on March 8, 2007 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint received by the Town of Barnstable. The following violations of the State Sanitary Code were observed: 105 CMR 410.482—Smoke Detectors.No smoke detectors observed within home. 105 CMR 410.300 & 310 CMR 15.00—.Sanitary Drainage System Required. Observed six bedrooms within home when septic (permit# 82-73) capacity is only for three bedrooms. The following violations of the Town of Barnstable Code were observed: 1§ 70-4—Certificate of Registration. Rental property is not registered with Town of Barnstable Health Department. Prohibition. Observed seven cars parked at home overnight when only four are allowed. QAOrder letters\Housing violations\23 Uncle Willie's Way.doc You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by installing smoke detectors in accordance with Mass Fire Codes. You are directed to correct the violations listed above within fourteen (14) days of your receipt of this notice by either upgrading septic system to accommodate for extra bedrooms or by removing bedrooms (this must be done by removing mattresses and bedroom door and making opening into room 5' wide); and by removing mattresses in basement and door to basement and making the opening 5' wide. 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 ORDE OF TH BOARD OF HEALTH omas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Timothy O'Connell, Health Inspector QAOrder letters\Housing violations\23 Uncle Willie's Way.doc Certified Mail#0000 0000 0000 0000 0000 t Town of Barnstable Regulatory Serviees Thomas F. Geiler, Director Public Health Division Thomas Mclean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 LAO date t addreo city,state,zip 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 g3 W,,� was inspected O (Address) on 3 / / -7 by , Health Inspector for the Town (date) (Inspector's name) of Barnstable, (Reason for inspection) The following violation(s) of the State Sanitary Code were observed: State code violation number- iolation descri 105 CMR 410. '1 _ a� , 105 CMR 410. 3 IYD 310 a}_8 _7.3' p off Q:\Order letters\Housing violations\Rental ordinance\template.doc L 105 CMR 410. The following violation(s) of the Town of Barnstable Code were observed: Town code jl - •olation description) . §170--_q_ - !, _ 3 �11- b-��-t,ert,�.t -� Cw� �t.�i�wQ c � - e-- You'are directed to correct the violations listed above within of your receipt of this notice by T �C#� --- � _n 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 Town of Barnstable Cc: (Name,tenant,owner,Fire Dept.,Building Dept....) Cc: (Health inspector's name) (Generic codes located at QAOrder letters\Housing violations\Rental Ordinance\GENERIC CODES.DOC) QAOrder letters\Housing violations\Rental ordinance\template.doc . , Parcel Detail Page 1 of 3 73 _4 a0. `'`t a �Alut;;fi r c7Lk Wit'- e:?i r2y.4 Logged In As: Parcel I Detail etail Thursday, Ma 1 lP•arrccel Lookup Parcellnfo Parcel ID 292-308W Developer LOT 5 m Lot�au_� Location p23 UNCLE WILLIES WAY Pri Frontage 210 ......._ Sec Sec Road Frontage village!HYANNIS Fire District HYANNIS .__... Sewer Acct Road Index 1752 Interactive Map i " M Owner Info 5(6 —� 7 Owner!MAIOCHI, JAQUELINE Co-owner Streetl PO BOX 1292 Street2 city lHYANNIS State MA j Zip 02601 Country IUS - Land Info Acres 0.31 useSingle Fam MDL-01 zoning �RB Nghbd 0106 Topography!Level Road Paved -- - Utilities Septic,Gas,Public Water Location L Construction Info Building 1 of 1 Year[1983_ Roof . � Ext Woo S Built: Struct,Gable/Hip d hingle- Wall r Effect 25 11 ROOf IAs h/F GIs/Cm AC None Area , � Cover� p p � Type Int Bed _._.._. Style i Ranch f Drywall 84 Bedrooms Wall' Rooms r, Model j Residential Int! Bath 1 Full Floor Heat r_-- _- ;_ Total Grade!Average Type IHot Water Rooms 17 Rooms htt ://iss 1/intranet/ ro data/ParcelDetail.as x?ID=23157 3/8/2007 P q p P P Parcel Detail Page 2 of 3 r Heat _ , Found- stories 1 Story 1 Fuel`oil ation Poured Conc. ! . Permit History Issue Date Purpose Permit# Amount Insp Date . Comments Visit History Date Who Purpose 1/9/2004 12:00:00 AM Paul Talbot Meas/Est 2/16/2001 12:00:00 AM SM Meas/Listed 9/15/1987 12:00:00 AM ML - Sal .. . ....--........ _......... Line Sale Date Owner Book/Page Sale P 1 8/27/2003 MAIOCHI, JAQUELINE 17545/003 2 8/27/2003 WOLFINGER, ROBERT F 17545/001 3 2/12/2001 WOLFINGER, ROBERT F &THOMAS J 13554/034 4 WOLFINGER, ROBERT F 3259/013 Assessment History . Save# Year Building Value XF Value OB Value Land Value Total Parcf 1 2007 $225,500 $3,500 $600 $165,700 2 2006 $196,000 $3,500 $700 $147,100 3 2005 $176,200 $3,400 $700 $133,200 4 2004 $143,000 $3,400 $700 $113,200 5 2003 $131,400 $3,400 $700 $30,300 ; 6 2002 $131,400 $3,400 $700 $30,300 7 2001 $131,400 $3,400 $0 $30,300 8 2000 $99,300 $3,300 $0 $19,800 9 1999 $99,300 $3,300 $0 $19,800 10 1998 $99,300 $3,300 $0 $19,800 11 1997 $98,900 $0 $0 $19,800 12 1996 $98,900 $0 $0 $19,800 13 1995 $98,900 $0 $0 $19,800 http::Hissql/Intranet/propdata/ParcelDetail.aspx?ID=23157 3/8/2007 FORM30 CHnW HOBBSB WARREN'M THE COMMONWEALTH OF MASSACHUSETTS ' BOARD O ALTH ` CITY/TOW N W DEPARTMENT e ADDRESS C 50% GSM J"� Sye� -- TELEPHONE Address QM `T Occupant—, Floor -_Apartment No._ No. f Occupants to �. No.of Habitable Rooms No.Sleeping Rooms--- No. dwelling or rooming units - No.Ston _ Name and address of owner _ 7`3 -- - — Remarks Reg. Vio. YARD Out Bld s.: Fences: 59-3 C"K 6 Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : r STRUCTURE INT. Hall,Stairway: Obst'n.: O Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents.- PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 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 r Bedroom 2 Bedroom 3 Q 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: y 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 PENALTIES OF PERJURY." T T INSPECTOR TITLE A.M. DATE 3 _ TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION 7T�L 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 fal 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). (I) 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 mainiain 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 overing 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. rp `FORM30 CII�W� Hosss.awaRaEN' THE COMfv10N.WEALTH OF MASSACHUSETTS D OF:,-HEALTH . CITY/TOWN w r �4,JJC�.. a DEPARTMENT — ADDRESS ' GSM v0"e .��`(J✓� ����'�� TELEPHONE, !�,} �, Address L Occupant Floor Apartment No No.of Occupants ._ 41, No. of Habitable Rooms__ _, _ No.Sleeping,Rooms -: No. dwelling or rooming units__ _ -; No.Stories Name,and address of,ownery_ ✓Vv lAp F` .�jr""° Remarks Reg._Vio. YARD Out Bld s.'. Fences'' c rt , —7 Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Ste ,Stairs, Porches: Dual Egress:'and..Obst'n.:: ❑ B 0 F .❑ M Doors,Windows: " Roof Gutters, Dr.ams.;. Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dam ness; Stairs: . Lighting: r M t STRUCTURE INT. Hall,Stairway: `)A) ���i1 A Obst'n:: O � . Hall, Floor,Wal1,'Ceilin r Hall Lighting: Hall.Windows. . HEATING .Chimneys: Central ❑ Y ❑ N Equip. Repair w TYPE:_ .._r , .Stacks,Flues,Vents. ' PLUMBING: Supply Line: ❑ MS ❑ST p P Waste Line: Tanks Safet 'and Vents (t 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. Panty Den LivingRoom �. Bedroom 1 i� -�� a � Bedroom 2 Bedroom 3 Bedroom4 Hot Water Facil. Sup.Ten., Gas Oil; El6ct,. Stacks;Flues,Vents,Safeties Kitchen Facilities Sink Stove Bathing,Toilet Facil Vent., Plumb.,Sanit n.: ,. . WasMBasin,Shower or Tub: .. _ Infestation Rats, Mice, Roaches or Other:' Egress Dual and Obst'n: General, BuildingPosted 'Locks on Doors: ONE OR,MORE OF THE VIOLATIONS CHECKED:ABOVEIS 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) . `+t "THIS INSPECTION REPORT IS.SIGNED AND CERTIFIED UNDER THE PAINS AND : PENALTIES OF PERJURY." y * INSPECTOR �"" ' I TITLE A.M. DATE f O TIME P.M. 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 heaith, 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 L10.100 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 wit-iin 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 disoosal 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 -05 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 ma ntain 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 cr 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. Enviro-Safe Corporation 1.4B)a.n Sebastian-Drier Sandwich MA 02563 PIl (508) 888-5478 FX (508) 888-9093 February 19,2008 Ms.Julie Hutcheson Massachusetts Department of Environmental Protection Southeast Regional Office 20 Riverside Drive Lakeville,MA 02347 RE: Enviro-Safe Corporation Emergency Response RTN #4-21070 23 Uncle Willy's Way Hyannis,MA .Dear Ms: Hutceeson: - On February_15, 2008, ENVIRO-SAFE was contacted by Ronaldo Coehlo, property owner of 23 Uncle Willy's Way, Hyannis, MA. Mr. Coehlo requested that ENVIRO-SAFE mobilize to his property to perform cleanup activities resulting from overflowing heating oil buckets that had been stored inside a van located in his driveway. Rainwater which entered.the van through a large hole in the van roof caused the oil buckets to overflow, and stream down the driveway along the shoulder of the road and into a catch basin on Uncle Willy's Way,Hyannis,MA. ENVIRO-SAFE arrived at the site on February 15,2008 at approximately 9:00 AM and was met by Donna Miorandi of the Barnstable Board of Health as we all as a representative of the Hyannis Fire Department. ENVIRO-SAFE swept up the Speedi Dri (put down by Fire Department) into a 55 gallon drum and transported off site. In addition, ENIVRO- SAFE mobilized a vacuum truck to the site to remove liquids from the catch basin as well as the residual oil and water located in the buckets inside of the van. ENVIRO-SAFE did not conduct a confined space entry of the catch basin. It should be noted that some of the oil had entered a.large crack in the asphalt roadway. ENVIRO-SAFE conducted'no confirmatory sampling or testing, nor do we make any further representations at the site. Copies of the daily work sheets documenting these activities as well as copies of the manifests used for the removal of wastes form the property are attached. If you have any further questions or if I can be of any more service to you, please do not hesitate to contact me. I can be reached at 508-888-5478 or 508-737-4109. Thank you and feel free to contact me if you have any questions. Regards, Heather M. two( General Manager Enviro-Safe Corporation Cc: Donna Miorandi-Barnstable Board of Health e , Enviro-Safe Corporation ; Daily Work Sheet Environmental Services •' 14B Jan Sebastian Drive Job Number- Sandwich, MA 02563 Date (508) 888-5478 / Fax(508) 888-9093 Sheet Number ` of Customer: Foreman/Supervisor: ol Job Location: ° 1 Day of Week: 0 Tu W ® Sat Sun �} o Shift: 1 1 3 Price:TO Contract: Temperature Weather Labor and Personnel Title/Job Description Employee Prot, Per Depart Arrive Depart Arrive Number Level Diem Base Site Site Base O E ui ment Type of Equipment Vehicle ID Depart Arrive. Depart Arrive Base Site Site Base 123p 1 U6 143o igpp Supplies/Materials u con rac rs *Polyeth'ylene QUANTITY TYPE QUANTITY SUBCONTRACTOR COMPANY HOURS/UNITS Spec.,Pers.Prot. Survey Eqpt Compressor Radios Sorbents Press.Washer I1 Miscellaneous C ges J Disoosal (Bulk Quantities Subject to Disposal Facility Verification) Permits Req'd? ❑ Yes No Type: Quantity Manifest or B/L Number Permits Issued? ❑Yes o Bulk Liquid Z Analyses Req'd? ❑ Yes 4 No Type: Bulk liquid By ESC❑ By Customer ❑ Bulk Solids Sample Numbers: Bulk Solids Drums(total) Other: Other JOB DESCRIPTION (Activity Summary-add sheets as needed) w s � vd ;11 V °p•'� Aa 41 d wt were Si le left in a Clean and Satis ctory Condition? ❑Yes ❑ No M If&,0► 10CM&L "Im, Remarks: Job Complete? ❑ Yes ❑ No Remarks: Customer signs as accepted the terms,quantities,and other information listed above;agrees that the services have bee rovided in o satisf ry manner,and that he/she is responsible for the cost incurred along with the terms and conditions contained on the Contract Initiation Form. X 2. 4- 8 Customer Signature Date vir ata Representative White•Joh Folder Yellow A(counfing- Pink ustomer r t Published.by J.J.KELLER 8 ASSOCIATES,INC.,Neenah,WI•USA•(800)327-6868•www.jjkeller.00m•Printed in the United States 167-BLS-lb 6 10495 Please print or type.(Form designed.for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest TracId Number (]p WASTE MANIFEST _ 3 .9 S Z 4 3 0 8= i3_ '7 0 O 2 6 V 2 1 J O J J K 5.Generator's Name,and Mailing Address Generator's Site Address(if different than mailing address) RONTD COELHO �Ap� 21 UNCLE WILLTES TRAY r� TS. RSA f�2'rJi General,s P one: 6.Transporter 1 Company Name U.S.EPA ID Number =ramM A C3 7.Transporter 2 Company Name U.S.EPA ID Number • r ' 8.Designated Facility Name and Site Address U.S.EPA ID Number 263 HOW3RD STRUT Facility's Phone: q,7 A_ a I— A 4 7 7 4 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class ID Number, a 10.Containers 11.Total 12.Unit HM and Packing.Group{if any)) 13:Waste Codes No. Type Quantity, VVLNol. o 0 Ncm—SKIT/N c=—RCPA Regulated Material,: V MA 9 D Pr W r �1 z 2. W 3. 4 z. 14.Special Handling Instructions and Additional Information 15. GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are Uly and accurately described above by the proper shipping name,and are Classified,packaged, marked and labeled/placarded,.and are in all respects improper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(•If l aX s all quanti generator);is'true. Ge tors/Offeror's Printedfryped Name Signore Month oDay Year ®� 15 16.International Shipments ❑Import to U.S. Export from U.S. Port of entry/exit: Transporter signature(for exports only): - Dale leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/ryped Name.O Signature Month Day Year z Transporter 2 Printed/Typed Name. Signature QMonth Day. Year - 18.Discrepancy _ 18a.:Discrepancy Indication Space Quantity ❑Type yp Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) w U.S.EPA ID Number Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) F— Month .Day Year Q z: 0 19.Hazardous WastaiReport Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU C 1• 2: . 4. 3. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a Printed/Typed Name Signature` Month Day Year i Published by J.J.KELLER&ASSOCIATES,INC.,Neenah,WI•USA•(800)327.6868•www.jjkeller.com•Printed in the United States 167-BLS-C.6 1.0495 Please print or type.(Form designed for use on elite(1 2-pitch)typewriter.) Form Approved.OMB No.2050=0039 1.Generator ID Number I UNIFORM HA2ARDOWS 2.Page 1 of 3.Emerge'ncy Response Phone 4.'Manifest 7rac�k+in��``Number ((�� ([�� WASTE MANIFEST M g S 0 8 3 8 5 1 + B 508-888-5478 O O 2 6 V Z 1 J J JJK 5.Generator s Name and Mailing Address Generator's Site Address(if different than mailing address) RONALD COELHO 23 UNCLE WILLIES WAY SAVE .gyb_N I S, %,A 0 2 r:0 3 .. Generators Phone: -a _- - ni 6.Transporter 1 Company Name U.S.EPA ID Number ` -~-ftr M A O 3 0 0 t3 0 1 6 1 7 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Oleon's-Gre�nh©users 590 South Street East lxrtvmham. M 0276 7 Facility's Phone: tt _ _ , M A D t; 5 9 7 3 3 3. 7 8 ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 110-Containers 11.Total 12.Unit HM. and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt./Vol. 1. Y T a id.�.latf7; PetroleumLrtl 3 e � Lati�Ili z 2. LU `3. LL- 14.SpWa8L'ons apd Adfitipgal Information" 1. 1`a�OD-t:�3 C'II'E'f?+D>:L�r3t� rwTL/iN71't'i�i� 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all.respects in proper condition for transport according to applicable intemational and national governmental regulations.If export.shipment and I am the Primary Exporter,1 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify thatfhe waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b).(if I am. smaltquantity.generator)is true. Ge _ rslOffer6r sPrintedfryped Name `Signat Month Day Year Z .16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: U 17.Transporter Acknowledgment of Receipt of Matepai ' Trans rter 1 Pri rr ed Na Pod YP Signature Month DaY�, a CL d t. \ L� ca ZZ Transporter 2 Printedrryped Name Signature Month Day D Year t- 18.Discrepancy 18a.Discrepancy Indicatioon Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Aftemate Facility(or Generator) U.S.EPA ID Number J. V 'Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2• T 14. I20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Commonwealth of Massachusetts 3 / = Title 5 Official Inspection Form s• Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � wA, 23 Uncle Willies Way 30 c0 Property Address ] Jagueline Malochi Owner Owner's Name information is Hyannis MA 02601 04/20/08 required for y every 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. Important: A. General Information When filling out r- in forms on the _ computer,use 1. Inspector. r .� only the tab key to move your Michael Kellett cursor-do not �- use the return Name of Inspector key. Aardvark Environmental Inspections f Company Name P.O. Box 896 77 Company Address 1.. East Dennis MA �ip 2641 City/Town State Code 508-385-7608 S13742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 04/25/08 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,,if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 fail•08106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owner's Name information is required for Hyannis MA 02601 04/20/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System.Passes: Z 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 exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts F Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owner's Name information is required for Hyannis MA 02601 04/20/08 _ every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has aseptic 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. fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M s 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owner's Name information is required for Hyannis MA 02601 04/20/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 '/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. fail-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owner's Name information is required for Hyannis MA 02601 04/20/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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.] have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. fail•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5.of 15 4 Commonwealth of Massachusetts Title 5 Official ' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owner's Name information is required for Hyannis MA 02601 04/20/08 every page. City/Town 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? El ® 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)] fail-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owners Name information is required for Hyannis MA 02601 04/20/08 every page. Cityrrown State Zip Code Date of Inspection 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 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial industrial Flow Conditions: Type of Establishment: Design flow(bas ed on 310 CMR 15.203): Gauons per d p y(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): fail•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Uncle Willies Way Property Address Jagueline Malochi Owner Owner's Name information is Y required for Hyannis MA 02601 04/20/08 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ cess Single ool 9 p ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no).(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 02/19/83 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No fail-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Y u Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Uncle Willies Way Property Address Jagueline Malochi Owner Owner's Name information is required for Hyannis MA 02601 04/20/08 every page. City/Town State . Zip Code Date of Inspection D. System Information (coot.) Building Sewer(locate on site plan): Depth below grade: 2.8 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: 2.1feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------- Dimensions: '° 1000 gal Sludge depth: 2„ Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 5° Distance from bottom of scum to bottom of outlet tee or baffle 161, How were dimensions determined? measured fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Uncle Willies Way Property Address. Jaqueline Malochi Owner Owner's Name information is required for Hyannis MA 02601 04/20/08 ' every page. Citylrown 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.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet 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: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owner's Name information is required for H annis MA 02601 04/20/08 Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc'): Pump Chamber(locate on site plan): Pumps in working order' ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No fail-o8im Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owner's Name information is Hyannis MA 02601 04/20/08 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition-of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil;signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): This system has 2 6'x6' precast pits surrounded by afoot of stone. There was no sign of ponding or failure. fail-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts a Title 5 official Inspection Fora - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owners Name information is required for Hyannis MA 02601 04/20/08 every page. City/Town State Zip Code Date of Inspection- D. System Information (cont.) 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 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.).- fail-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owner's Name information is H required for annis MA 02601 04/20/08 y every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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. qj `G D 3� � e 6� fail-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 23 Uncle Willies Way Property Address Jaqueline Malochi Owner Owners Name information is required for Hyannis MA 02601 04/20/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar Shallow wells Estimated depth to ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20 feet. fail-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 THE Town of Barnstable �p Tp� Regulatory Services saruvsres,e Thomas F. Geiler,Director p,ED �A Public Health.Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,.Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number.of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. A`T ❑ Delete J Olt '. MA I 2/14/2008 001 A280106 0 ❑ Change NFIRS - 1 •, State Incident Date Station Incident Number Exposure ❑ No Activity Basic I Check this box to indicate that the address for this incident is provided on the W Idland Fire . T7 Location Module in Section B"Alternative Location Specification".Use only for wildland fires. Census Tract 30 ❑ St�Intersection ��etAddress Int❑ e 23 uV (UNCLE WAY WILLIES WAY u N In*ont of Number/Milepost ,Prefix Street or Highway - Street Type Suffix I Hear of I (Hyannis I A 02601 ❑ Adjacent to Apt./Suite/Room City State Zip Code ❑ Directions IlAlecia I ❑ Cross street or directions,as applicable C Incident Type E1 Dates&Times Midnight is 0000 �2 Shifts&Alarms 413 IOiI or other combustible Local Option IncidentType (liquid spill Check boxes if Month Day Year Hour Min dates are the 1 ALARM alwa s required LC still J Aid Given_Received same as Alain' Y q Date. Shift Alarm 02 14 2008 16:45 platoon No OfAlarmUistrict 1 ❑ Mutual aid recei ed II � II I ARRIVAL required,unless canceled or did not arrive 2 ❑ Automatic aid recv. u I ® Arrival 02 14 2008 16:49 E3 Special Studies Their FDID Their 3 ❑ Mutual aid given state Local Option 4 ❑ Automatic aid given CONTROLLED optional,except torwildland Tres L> 5 ❑ Other aid given ❑ Controlled u u N ® None Thelr.lncident Number Last'Unit LAST UNIT CLEARED,required except wildland fire Special I Special ( ® Cleared 02 14 2008 18:21 Study ID# Study Value L Acfons Taken G1 Resources G2 Estimated Dollar Losses &Values is j!-^ • Check this box and skip this section if an LOSSES: Required for all fires if known. Optional for non fires L 41: ,:Identify,analyze hazardous materials ❑ Apparatus or Personnel form is used.•. Primary Action Taken(1) Apparatus Personnel None „i Property I ❑ 44; )Hazardous materials leak control& Suppression u � 6 Contents I ❑ Additional ActionTaken(2) EMS 0 L 0 PRE-INCIDENT VALUE: optional 82 JNotify other agencies. Other 0 L 0 Property I ❑ Additional Action Taken(3) Check box if resource counts include aid ❑ received resources. Contents I ❑ Completed Modules H1 Casualties ® None H3 Hazardous Materials Release Mixed Use Property Deaths Injuries N❑ None C]Fire-2 Fire NNE Not mixed I❑ Structure-3 Service I n n 1 ❑ Natural gas: slow leak,no evacuation orHazMatactions 10 ❑ Assembly Use 9C]Civilian Fire Cas.-4 J 2 El Propane gas: <21 lb.tank(as in home BBOgrill) 20 ❑ Education use ❑,;Fire SeTV. CaSUalty I� I 3 ❑ Gasoline:vehicle fuel tank or portable container 33 '❑ Medical Use Civilian• �p� u 40 ❑ Residential use 0EMS-6 � 4 ❑ Kerosene:fuel burning equipment or portable storage 51 ❑ ROW Of stores 5 Diesel fuel/fuel oil: vehicle fuel tank or []HazMat-7 . Detector ® Portable stora g � ❑ Enclosed mall [] W i Ld;land Fire-8 H2 6 ❑ Household solvents:Home/office spill,cleanup only 58 ❑ Business&residential ,.d- Required for confirmed fires. 59 ❑ Office use 7 Motor oil:from engine or portable container Apparatus-9 ❑ 60 ❑ Industrial use ❑Personnel-10 10 Detector alerted occupants 8 ❑ Paint:from paint cans totaling<55 gallons 63 ❑ Military use r )a: 2❑:Detector did not alert them •0 ❑ Other: Special HazMat actions required or spill>55 gal., Please complete the HazMat form 65 ❑ Farm Use U❑ Unknown � ❑ Other mixed use erg. 'Property Use Structures 341 ❑ Clinic,Clinic T a yp infirmary 539 ❑ Household goods,sales,repairs 131 Church,place of worship 342 ❑ Doctor/dentist office 579 ❑ Motor vehicle/boat sales/repairs 161: Restaurant or cafeteria 361 ❑ Prison orjail,not juvenile 571 ❑ Gas or service station 162:• ❑. Bar/tavern or nightclub 419 El1-or'2-family dwelling 599 ❑ Business office 213 ❑ Elementary school lub kindergart. 429 El Multi-familydwelling. 615 ❑ Electric generating plant 215 ❑ High school or junior high 439 ❑ Rooming/boarding house 629 ❑ Laboratory/science lab ❑ 449 ❑ Commercial hotel or motel 700 ❑ Manufacturing plant 241 ❑ College,adult ed. ,459 ❑ Residential,board and care. 819 ❑ Livestock/poultry storage(barn) 311 Care facility for the aged 464'❑ Dormitory/barracks 882 ❑ Non-residential parking garage 331 ❑ Hospital 519 ❑ Food and beverage sales 891 ❑ 'Warehouse 4 Outside 124 ,, ❑ Playground or park 936 •❑ Vacant lot 981 ❑ Construction site 655 Crops or orchard 938 ❑ Graded/cared for plot of land 984 ❑ 'Industrial plant yard 669 Forest(timberland) ° 9<i1 ❑ Lake,river,stream f 807 Outdoor storage area ❑ "'Railroad right of way 919 ❑ Dump or sanitary landfill 960 ❑ Other street Look up and enter a Property Use p ry 961,❑ Highway/divided highway Property use code only rf 965 r 931. E, Open land or field you have NOT checked a I 1 h s1 962 ❑ Residential street/driveway Property Use box: Vehicle parking area .. . - NIIRS1 03/11 !+s.L•...rw..�.�rm..Y ,...A .,ax.„awsma'T„wt...mn...r�xw,.xl`+.--. .. .. ••' ... R N9 1'Z80106 EXP 0, 211412008 PAGE 1 OF 2 HYANNIS FIRE DEPARTMENT - MFIRS REPORT. i i '.Person/Entity Involved - 508-364-0440 Local option Business name(if applicable). Phone Number .• sxif same address L�J IJosellto a IAbranteS I �� .incident location. Mr., Ms., Mrs. First Name MI Last Name Suffix Then skip,the three °. duplicate address 45 lines. ITevyaW Rd. Number/Milepost Prefix -Street or Highway Street Type Suffix Hyannis Post Office Box Apt./Suite/Room City Ma 1 02601 State Zip Code ❑ More people Involved? Check this box and attach Supplemental Forms(NFIRS-IS)as necessary. 1_ Owner ®Same as person involved? Y�2 Then check this box and.skip IJOSel.lt0 I508-364-0440 Local Coition the rest of this section. Business name(if applicable) Phone Number Chec address as k this box if same �Josellto' - _ u IAbranteS �J LLII incident location Mr.,Ms.,Mrs. First Name MI Last Name Suffix Then skip the three lines, duplicate 45 a lTeVyaW Rd I u u nes f., Number/Milepost Prefix Street or Highway - Street Type Suffix lu Hyannis Post Office Box Apt./Suite/Room City `.r Ma I 02601 of V State Zip Code i Remarks: Local 0olion 4;. .. More remarks?Check this box and attach Supplemental Forms ITEMS WITH A MUST ALWAYS BE COMPLETED! (NIFIRSAS)as necessary. ® pp L Authorization s „I198501 (Dean L Melanson I I Deputy Chief I I Suppression 02 14 2008 Officer in charge ID Signature' Position or rank Assignment Month Day Year `same as:.;:.• - •Oificenn. charge -� 197702 I (Roger E Cadrin Lieutenant Suppression 02 14 2008 -- Member making report ID Signature Position or rank Assignment Month Day Year -`sb AhzYu°44,�n.. 77a,cv:IXh»,s,[3imcsw[.hEi:reuiw+....,:,riXw.so22m.u.....uC,.,�viwa,.:x ,... c,v4 c.., ••.. ww,.,:, ..... •• .. „uF,r.,.0 .,.» :,»un - A'280106 -_Exp 0, 211412008 23 UNCLE WILLIES WAY page 2 of 2 HYANNIS FIRE DEPARTMENT - MFIRS REPORT t-' El Del 61�2`� ll �'A I 2/14/2008 1 OOI ' A280106 I 0 .� ❑ Change N - 1S 'F'61D, State rlh Incident Date�1l-, Station Incident Number. Exposure 9 SUPp S�ementa� 51 t � Person/Entity Involved I Local 0 508-364-0440 Option - Business name(if applicable) ter - - Phone Number - 0Check this box if —t JOSelltO same _ I u IAblanteS I ---- ro incident location. Mr., Ms., Mrs. First Name - MI Last Name :Suffix's r Then skip the three " duplicate address 45 Rd Imes ITeV aW y - •- Number/Milepost Prefix Street.or Highway Street Type Suffix t IIpp I A (Hyannis T5. Post Office Box Apt./Suite/Roam City Ma 0260.1 State Zip Code r c .•1<2 Person/Entity Involved 1 1508-778-2452 Local Option Business name(if applicable) Phone Number <3� .up n t . r © Chec address as kthisboxif same . I�ROnaldo 14-I � I -lCoelho incident location. Mr.,Ms.,Mrs. First Name MI Last Name suffix ?, Then skip the three - I I - v duplicate address lines, 23 L�J (UNCLE WILLIES I WAY � _ t Number/Milepost Prefix Street or Highway Street Type Suffix (Hyannis Post Office Offic,,e Box� Apt./Suite/Room City f � r � 02601 h State Zip Code _# h Person/Entity Involved �3 IT OB I I508-862-4644 F, Local Option Business name(if applicable) Phone Number11�101th inspector ❑ Check this box if IIDavid I:�I (Stanton ,L �. same address as incident location. Mr.,Ms., Mrs. First Name MI Last Name S,Suffix Then skip the three ' 'I neliicateaddress 200 IMaln Street Number/Milepost Prefix Street or Highway Street Type Suffix x I II I I y I . H anni s { Post Office Box Apt./Suite/Roam City ' Ma 1 02601. r „ State Zip Code ` k A ' g 1 NFRStt RevisionW% A2Rnrn6•= FXn n. FSc <<,FS(' q iv >>. 211412nnR HYANNTS FTRF DEPT. nanP 1 of 1 ' 01922 J MA I 2/14/2008 001% A280106 a ❑ Delete NFI is is State Incident Date Station Incident Number rIh Exposure �/h ❑ Change Supplemental ILLLrSSSS X2 Remarks 23 UNCLE WILLIES WAY s 4 Received a call from BPD reporting a fuel'leak from a van parked at 23 Uncle Willies Way. _: ¢ r"; t. We responded with E-823, upon arrival we found an econoline style van parked in the driveway of thhs address with an obvious fuel spill on the ground under the van and leading down the street to a nearby ' storm drain. When,we checked the van closer we discovered many uncovered containers of oil inside the van that seamed ' r to be the source of the spill that was caused when rain water leaked into the van through a hole in the roof Of the van overflowing the containers causing the oil to spill onto the ground. .F The storm drain had obvious evidence of oil in it from this spill so we requested a TOB BOH inspector to,d r the scene, Inspector Dave Staton arrived on scene shortly thereafter. After several attempts we finally contacted.Ronaldo Coelho inside the home who stated that the van belonged to a friend of his who wasn't home at this time. µ Ronalg6 Explained that when a home heating oil company delivered oil to the wrong address he and friends attempted to gather the oil in containers and deliver it to this address to use it to heat this home, bUt:,,w. fiefiTj they arrived with to Uncle Willies Way with the oil inside the van they discovered that the oil company 1-had.-already delivered the requested oil and therefore there was no place to put the oil at present so they left }t in the van in ira81i containers and 5 gallon'buckets. I�t Cadrin``called Captain Kristofferson to the scene along with Lt. Hubler from fire prevention to detemine the'co-rrect course of action. Deputy Melanson also arrived on scene to assist. The',Mass D.E.P. was notified by Dave Stanton TOB BOH. We used speedi dry and absorbent pads to i control,the spill and contain it. The spill involved several gallons of home heating oil and rieed.ed to"be f &'anegj, p by a licensed cleanup company. F The-vehicle owner was unable to come to the scene this evening and could not presently authorize payment '.to a,cleanup company, so, a decision was made by this department and the Board of Health Rep to allow the van to remain on scene for the evening since the fuel is presently contained. Arrangements will be made.in the morning with the vehicle owner to have the spill cleaned up. The battery of the van was disconnected by us and the vehicle locked and tagged with caution tape. BPD officer,was,on 4 y scene and was advised of the decision. i There was no`other property damaged and`no persons injured as'a result of the spill. L <,`` k�ra 3 ; dry.. ., .--....._,—..............................:.. ,... ... .a:tl= it. _ ._a,. _.>...+............ 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Via; " lit �.; y 114 Air", s x,- ,: � eJi' a 7a _. 4.;' �� __� �__ � __ '.� � '�I 4 :� j t �:.r Yf ((( v Ti a ,�i . .... - zf }c .. �,�y>7 � 5* �� F e � � � � i� �,., ;. �� r :. i �� �` .� z � cT� -�- ,� -• '� , nor �� ° � 0 <. �,,.. .. �� t� '��'�� _ F ,k i` a i � �' _ .� ,Y# t � d .,; ,. a y ...:..: i.A-. - O _ E� , _ �{ � � � # F �'��� �' �. �� �� .. � i s r a-,� � � � _.. y }f ``L' ' ' r: ��`. F �y i.�•'/;• — 'E, w i �� � � � ' , t , •�-. � T�� � ❑ Delete NFIRS - 1 01922 1 2/14/2008 001 A280106 I 0 Change , �t State * Incident Date Station Incident Number Exposul ❑ NO Activity asic ; Check this box to indicate that the address for this incident is provided on the Wildland Fire B Location Module in Section B"Alternative Location Specification".Use only for wildland fires. Census Tract I 30 ❑ Street Address I El Intersection 23 UNCLE WILLIES WAY WAY u Number/Milepost Prefix Street or Highway r \ Street Type Suffix ® In front of _ ❑ Rear of (Hyannis � l�,a�l� MA� I 02601 ❑ Adjacent to Apt./Suite/Room City q a r Staate Zip Code ❑ Directions IIAlecia ❑ Cross street or directions,as applicable ,C Incident Type E1 Dates &Times Midnight is0000 C E2 . Shifts&Alarms 413 Oil or other combustible Local Option Incident.Type Iliquid sUill Check boxes if Month Day Year Hour Min dates are the I k-' still u Aid Given—Received same as Alarm ALARM always required I Date. Shift or No Of Alarm�istrict Alarm 02 14 2008 16:451 platoon 1 ❑ Mutual aid received II I ARRIVAL required,unless canceled or did not arrive 2 ❑ Automatic aid recv. U u E3 Special Studies Their FDID Their Arrival 02 14 2008 16:49 G p 3. ❑ Mutual aid given State Local Option CONTROLLED optional,except for wildland fires 4 ❑ Automatic aid given L� U 5 ❑ Other al given ❑ Controlled •N ® None Their Incident Number I Last Unit LAST UNIT CLEARED,required except wildland fire Special ( Special J ® Cleared 02 14 2008 18:21 Study ID# Study Value Actions Taken C71 Resources C72 Estimated Dollar Losses &Values ❑ Check this box and skip this section if an LOSSES: Required for all fires if known. Optional for non fires. Apparatus or Personnel form is used. Identify,analyze hazardous materials si None; Primary.Action Taken(1) Apparatus Personnel Property I I ❑ Suppression 0 0 4:4 Hazardous materials leak control& (� Contents •Additional-Action:Taken(2) EMS 0 0 i ik 1 0 0 PRE-INCIDENT VALUE: optional i 82 LNotify other agencies. Other L 0 �0 Property I I ❑ Additional Achon.Taken(3) Check box if resource counts include aid `z ❑ received resources. Contents ❑ ) Completed Modules Ha Casualties ® None H3 Hazardous Materials Release I Mixed Use Property Deaths Injuries N❑ None Fire N N N Not mixed 1 ❑,,St uc.ture-3 Service U (� I I ❑ Natural gas:slow leak,no evacuation orHazMatactions 10 ❑ Assembly Use Civilian Fire Cas.-4 L 2 ❑ Propane gas: <21 lb.tank(as in home BBO grill 20.❑ Education use I n I 3 Gasoline:vehicle fuel tank or portable container 33 ❑ Medical use i]Fit-e Serv. Casualty- Civilian � 0 U ❑ 40 El Residential use ❑-EMS-6 4 ❑ Kerosene:fuel burning equipment or portable storage 51 ❑ Row of stores 5 Diesel fuel/fuel OII:vehicle fuel tank or portable storage '+ E..1-1azMat-7 Detector ® ❑ Enclosed mall H2 6 ❑ Household solvents:Home/office spill,cleanup only 58 ❑ Business&residential Q.Wildland Fire-8 Required for confirmed fires. ] Motor oil:from engine or portable container 59 ❑ Office use Apparatus-9 ❑ 60 ❑ Industrial use 1 ❑ Detector alerted occupants H Paint:from paint cans totaling c55 gallons ❑ Military use ❑Personnel-10 ❑ 63 2❑:Detector did not alert them 0 ❑ Other:special HazMat actions required or spill>55 gal., 65 ❑ Farm use U❑ I Unknown Please complete the HazMat form. 00 ❑ Other mixed use Property Use Structures Type infirmary ❑ Household goods,sales,repairs ,� 341 ❑ Clinic,Clinic T e infirma 539 131. Church,place of worship 342 ❑ Doctor/dentist office 579 ❑ Motor vehicle/boat sales/repairs ❑ 361 ❑ Prison or jail,not juvenile 571 ❑ Gas or service station 161 Restaurant or cafeteria 419 ❑ 1-or 2-family dwelling 599 El Business office 162 ;❑ Bar/tavern or nightclub 429 ❑ Multi-familydwelling 213 Elementary school or kindergart. dwe 9 615 ❑ Electric generating plant ❑ 439 ❑ Rooming/boarding house 629 ❑ Laboratory/science lab y 215,:=- ❑ High school orjunior high 449 Commercial hotel or motel 700 ❑ Manufacturing plant 241 ElCollege,adult ed. 459 ❑ Residential,board and care 819 ❑ Livestock/poultry storage(barn) 311.;,. ❑ Care facility for the aged 4 ❑ Dormitory/barracks 882 ❑ Non-residential parking garage __ 331 ❑ Hospital 519 ❑ Food and beverage sales 891 ❑ Warehouse Outside 936 ❑ Vacant lot 981 - 124 Playground or park ❑ Construction site t ❑ 938 ❑ Graded/cared for plot of land 984 ❑ Industrial plant yard 655 Crops or orchard 669 ❑ Forest(timberland) 946 ❑ Lake,river,stream r ❑ 951 ❑ Railroad right of way 807 ❑ Outdoor storage area 960 ❑ Other street Look u and enter a I 919 ❑ Dumporsanitarylandfill 961 ProperttyUsecodeonlyif Property 965 931 Open land or field ❑ Highway/divided highway you have NOT checked a ❑ 962 ❑ Residential street/driveway Property Use box: Vehicle parking area i NFIR5-1 Revbion 0]l11r9 L_ A280106 - EXP 0, 211412008 PAGE 1 OF 2 _. HYANNIS FIRE DEPARTMENT - MFIRS REPORT k1Person/Entity Involved \ Local option 15 08-3 64-0440 . I ness name(if applicable) Phone Number Check this box if u same address as IJoselito I u �Abrantes I �� incident location. Mr.,Ms.,Mrs. First Name MI Last Name Suffix Then skip the three - - duplicate 45 �� TevyaW Rd line lines." . Number/Milepost Prefix Street or Highway Street Type Suffix L� Hyannis , Post Office Box Apt./Suite/Room City Ma 02601 State Zip Code El More people Involved? Check this box and attach Supplemental Forms(NFIRS-1S)as necessary. OWner ®Same as person involved? 2 ': Then check this box and skip IJoselito I508-364-0440 I r Local Option the rest of this section. Business name if applicable) ( Phone Number Check this box if IJOSehtO u IAbrantes same address as LLL_��� incident location. Mr., Ms.,Mrs. First Name M I Last Name Suffix Then skip the three I I duplicate address lines. 45 11 I Tevyaw Rd Number/Milepost Prefix Street or Highway Street Type Suffix I LHyannis I Post Office Box Apt./Suite/Room City - . Ma I 02601 State Zip Code �.,..:,,-...,_,.;e-.�_�.�..,_...y.._...t.-�.....��:.•c:.s„�..�.....,.�..,,uv�xas±.a:�r..:�.weaavmirs.,i..asv�,•�n: s.3:srs.,m.,...,. .z.::.s. �i.�......;:,•.�..a, ..�:.�^-,,...;,a,:x-:...��......�,W„�.-.�ax:srnr:.w.z� --��^s^u�.r;,:�r.���v Remarks: Local 9plion A ey �y w '3 A ^I n k 2 -P More remarks?Check this box and attach Supplemental Forms ITEMS WITH A MUST ALWAYS BE COMPLETED! (NFIRS-1S)as necessary. =N -'. �.:_.-.�:..._ ,tea:�_-�-_ .�._,--�,_._.:.._ :_�._._�:_...__.�_:=i,._=�.�.._:.,...�:� ,...,--. •> _;.e,_- .� M Authorization j ) 198501 I (Dean L Melanson I I Deputy Chief ( Suppression) 02 1 L 14 I 12008 Officer in charge ID Signature Position or rank Assignment Month Day Year a -Check box if "same as - charIa. 1197702 Roger E Cadrin Lieutenant Su ression� 02 14 2008 Officer in _. .=J a.� I I �.. � I I I pp � I� I I II 11 -" --- - Member making report ID Signature' - - - Position or rank Assignment Month Day Year A280106 - Exo 0, 211412008 23 UNCLE WILLIES WAY page 2 of 2 HYANNIS FIRE DEPARTMENT - MFIRS REPORT Li � T�� � El Delete NFIRS - 1S i 0022 2/14/2008 001 1 A280106 0 State Jl Incident Date rlL otation Incident Number Ex El Change Supplemental K2 Rem°a^jrks 2 3 UNCLE WILLIES WAY Received a call from BPD reporting a fuel leak from a van parked at 23 Uncle Willies Way. We responded with E-823, upon arrival we found an econoline style van parked in the driveway of this address with an obvious fuel spill on the ground under the van and leading down the street to a nearby storm drain. When we checked the van closer we discovered many uncovered containers of oil inside the van that seamed ' to be the source of the spill that was caused when rain water leaked into the van through a hole in the roof of the van overflowing the containers causing the oil to spill onto the ground. - The storm drain had obvious evidence of oil in it from this spill so we requested a TOB BOH inspector to the scene, Inspector Dave Staton arrived on scene shortly thereafter. Y:.After .several attempts we finally contacted Ronaldo Coelho inside the home who stated that the van belonged to a friend of his who wasn't home at this time. YN r Ronalddo Explained that when a home heating oil company delivered oil to the wrong address he and friends .�attempte to gather the oil in containers and deliver it to this address to use it to heat this home, but when (they �rriwed with to Uncle Willies Way with the oil inside the van they discovered that the oil company hid -1'--dy delivered the requested oil and therefore there was no place to put the oil at present so they left w it n,*T'he van in trash containers and 5 gallon buckets. Li.:Cadrin called Captain Kristofferson to the scene along with Lt. Hubler from fire prevention to determine the correct course of action. Deputy Melaiison also arrived on scene to assist. i.:'T,he Mass D.E.P. was notified by Dave Stanton TOB BOH. We used speedi dry and absorbent pads to control the spill and contain it. The spill involved several gallons of home heating oil and needed to be cleaned up by a licensed cleanup company. y Re. vehicle owner was unable to come to the scene this evening and could not presently authorize payment .cleanup company, so a decision was made by this department and.the Board of Health Rep to allow the . van to remain on scene for the evening since the fuel is presently contained. ra Arn ements will be made in the morning with the vehicle owner to have the spill ill cleaned u The batter t.. g, ,. b p. y ;;-l-0 the van was disconnected by us and the vehicle locked and tagged with caution tape. BPD officer was on <3 J: 'sceiie.and was advised of the decision. These`was no other property damaged and no persons injured as a result of the spill. i � y � T�� � '� ❑ Delete NFIRS - 1S. .) „01,922 11 � AI 2/14/2008 001 I A280106 I � } YDID �Jh State* Incident Date rlh Station Incident Number �t Exposure El Change Supplemental i ;n( 7^n( Ire( 7nj Person/Entity Involved �� 1508-364-0440 LocatOption Business name(if applicable) Phone Number > same address as tliisbox same if u IJoselito I u IAbrantes ' t incident"location. Mr.,Ms.,Mrs. First Name - MI Last Name Suffix q :*.Then-skip the three duplicate address lines. 45 J I Tevyaw Rd _ �. Number/Milepost Prefix Street or Highway Street Type Suffix y I � I IHyannis ,I Post Office Box Apt./Suite/Room city Ma I 02601 State Zip Code '-. :a 4...�-.a•Ya_m__,.21.i__l.C�_.c<�.�u;d�..._:._...`...Y'.1:.�...ix-.�S ..a .r-ScS'4:�'.ilt��h✓,.s-�YP1:u�- �..v... ....w.. ti�6u2:'d.^..".2::.1..vo:IalY:..•y:v:L+'�.»Y��S"i..�>..�Y,n .,..,.x __ . 1R2*iiC.i•�GgJ2U..uv:.�r.:..�?� Person/Entity nti Involved I508-778-2452 I 1 Local Option Business name(if applicable) Phone Number UUpa 1. Check this box if J I Ronaldo I U I Coelho I �� same address as incident location. Mr., Ms.,Mrs. First Name MI Last Name Suffix =. 'Then skip the,three I I dues. eateaddress 23 L�J (UNCLE WILLIES I I WAY I IWAY1 Number/Milepost Prefix Street or Highway I Street Type Suffix y .� IHyannis w Post Office Box Apt./Suite/Room City i t ' IMA I 02601 State Zip Code .Ja ..-.>t.....e:..-._.._.+.->m..3v_�......�G.e.+i.i.:<<-c - .�..._.-.�...::.:tG.1w•i::An�.L:rt'-• r:.i�3^^-,'_^.,5."�` `oC.£:YY..r£fr>GL.t'...^.u'�'i'.f21'::.£�i'u--.;..r�r>-xz>1•'q.-3CG I ` Person/Entity Involved�3 IT O B ( I508-862-4644 I �, Local Option Business name(if applicable) Phone Number ill Ss't"CiU 7 Check address as I� IDaVId I u (Stanton ( I� same address as incident location. Mr., Ms.,Mrs. First Name MI Last Name Suffix Then skip the three liinesicateaddress 200 U IMaln Street I U u Number/Milepost Prefix Street or Highway Street Type Suffixy I I I I Hyannis Post Office Box Apt./Suite/Room city Ma 02601 State Zip Code y - NFIRS-11 Revision MISS ri�)saninr, _ Pvn n Fcr— HYAA/A/Tq FTRF nFPT n»a i nF 1 Hyannis Fire Department Log ,Database v4. Call Source BPD Time 1$:45 Date 2/14/08 Alarm No. Call Back Ext. #809 Enter name of business here Type of Call IFuel / Li uid S ill Incident No. A280106 Lookup Business Name Address 23 UNCLE WILLIES WAY Vicinity/ Area Mutual Aid District 0 Low No. 10 High No. 141 Census 30 B.p.d. Unit Off On Loc. With Odor Of Diesel ? Spill Requesting Engine To Investigate. Lt. Cadrin Requests Board Of Health, Spill Has Extended Into Storm System. David Stanton - Board Of Health Notified) Request For Capt. To Scene. Board Of Health On Scene. 17:02 Fire Prevention Requested To Scene. 17:05 Lt. Hubler To Respond. Lt Cadrin Reports Scene Secure 18:22 Apparatus Time Time Start Time End Time Time in Time Time out on loc Mileage to CCH Mileage at CCH service return at Ot. 823 16:47 16:49 18:21 18:21 18:28 803 :1 .59 17:02 17:16 << 17:16 17:30 805 17:07 17:12 18:21 a ;y NOTES TO THE FILE Date: February 21, 2008 Location: 23 Uncle Willies Way Hyannis RE: Home heating oil spill Inspector: Cynthia Martin On February 19, 2008 I performed a follow-up visit at the above location. Residual speedy-dry-was evident on the edge of the street and a strong oil odor was evident. The van which had housed the oil was now parked in the backyard of the property and I verified that it had bee emptied of oil.' Mr. Ronaldo Coelho provided me with a manifest for the disposal of 155 gallons of waste oil (MA97) by Enviro-Safe of Sandwich. In a telephone conversation with Julie Hutcheson, DEP, I was informed that Enviro-Safe had removed the oil from the van, all contaminated absorbent material and the contents of the storm drain. Based on information from Enviro-Safe, DEP concluded that the spill consisted of less than 10 gallons of oil and that no further action would be required. I was advised, however, that if additional observations indicated potential, further clean up DEP could be contacted. �,x r COIONTWEALTH OF YLAS.SACHUSETTS ✓ E�LECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS / DEPARTnIENT OF ENVIRONMENTAL P OTECTION 5 RECEIVED �\ JUL p 2 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION q MAR Property Address: :23 C/N 1 VIL PARCEL / LOT 5 Owner's Name: /i'.. ,•�'t -� Tyr, LG!,j�'n���� '- Owner'sAddress: tye5r.V9,.g, S .r lJ,.r i3G. /a s M 17 Date of Inspection: Name of Inspector: (please print) JO�k, Iq flc� Company Name: •Jof,, /�g tc : :; 11�' ��yvic.y Mailing Address:�)) 10 ST ` Telephone Number: ;i� - r/2 G 7 72 r% CERTIFICATION STATENIENT 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. 15.3•t0 of Title CMR 15.000). The system: S (310 • t� Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authoriry / Fails Inspector's Signature: `i•-- t�i� - Date: The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system.owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.' Notes and Comments "**This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 1 OFFICIAi, INSPECI'10\ FOR11I -N6 ORVOI UNTARY;ASSESSMji:NTS;; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .' , PART A CERTIFICATION (continued)' Property Address: 23 Owner: Date of Inspection: Inspectio❑ Summary: Check A,B,C,D or E/ALWAYS completeall of setIloe.D A. System Passes: tXSy 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. Commen ts: B. System Conditionally Passes: One or more system components as described in :he"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 exfiltration o.tank faihrre is imminent:System will pass inspection if the existingtank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break.oul or ziigh 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 pipc(s)arc rcpL?ced 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 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSUR-ACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART A, CERTIFICATION.(continued) Property Address: ?3 L!il Lle Owner: Ao��r� Date of Inspection: 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 wanner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the 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 tanl:and SAS and the SAS is less than 100 feet but 50 feet or more frottl a private water supply well". Method used to determine distance `This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other.: 3 Page 4 of 11 OFFICIAL INSPECTION FORM —NOT, FOR VOLUNTARY ASSESSMENTS .c� SUBSURFACE SE`VAGE DISPOSAL`SYSTEM:INSPEGTIONYORIN�'.-" r PART.A y:: : . r . CERTIFI CATION..(continued) Property Address: 13 1417 Owner: ACIA.eYf T",-, Date of Inspection: D. System Failure Criteria applicable to all systems:. ..•;, You must indicate"yes" or"no"to each of the following for all inspections Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool v Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool v 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 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. t, 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 00 feet but greater than'30•feet-from-a'yrivate water supply well with no acceptable water quality analysis. [This syste'tii passes if tht♦"N water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or sess than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must b:attached to this form.l �o (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve'a facility with a design flow of,10,000 gpd to 15,000 gpd• You must indicate either"yes" or"no" to each of the following: (The following criteria apply to large systems in addition to the critrria 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: 2.3 U,,t/e t(.LII ys Owner: X"'A, rf Date of Inspection: 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 _ _Z Were any of the system components pumped out in the previous two weeks? w 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: 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 CiviR 15.302(3)(b)J Page 6 of 1 1 OFFICIAL INSPECTION FORM -NOT FORY�OLIJNTA"ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM ..' '. PART C SYSTEN1.:INFORMATION Property Address: _2 3 Owner: /'0�e f r %�•� L�:.I� _...... .. Date of Inspection: G Y 4>-.,; FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design); Sf Number of bedrooms(actual): S� 1, DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x It-of bedrooms): '•",r"W Number of current residents: 0 Does residence have a garbage grinder(yes or no): lVo Is laundry on a separate sewage.system (yes or no): i✓,: [if yes separate inspection required] Laundrysystem inspected Y p (yes or no):— . Seasonal use: (yes or no): Ak, Water meter readings, if available (last 2 years usage(gpd)): 2 i��i . 2 2��0t;, , Sump pump(yes or no): Yo Last date of occupancy: _ •- v 3� COh1MERCIALfiNIDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gnd Basis of design flow(se ats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: ' OTHER(describe):. GENERAL INFORMATION .. ` ;'t:• `;j Pumping Records Source of information: Was system pumped as pan 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.Attach•a copy of the current operation.and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components, date installed (if mown)and source of information: Were sewage odors detected when arriving at the site (yes or no):— 6 Page 7 of l l OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: 2.3 (,ih:l1 Owner: /tCLJ:r/ °Y' LYE Lei/j ".y Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: :3c Materials of construction:_cast iron C40PV( '_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): to SEPTIC TANK:_(loca on site plan ) Depth below grade: 2�' .Material of construction:' concrJ ete) metal_fiberglass_polyethylene - other(explain)-If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of . certificate) Dimensions: r'A /c' Sludge depth: -2 Distance from top of sludge to bottom of outlet tee or baffle: -3f 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:1 _ ...,.. .,.. .... _ . . .... .. How were dimensions determined-- Piar1yr Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): p/' ,, ve 5 S�Q�1/N' 'f7u�t GREASE TRAP: _(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.): 7 . Page 8 of 1 I , OFFICIAL INSPECTION FORM—NOT:FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM-. PART C SYSTEM INFORMATION(continued) Property Address: 2;:5 u e Owner: /F'y41e*l Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of itrspe Lion iatatcim site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: ' Alarm in working order(yes or no):. Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: gL (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: o Comments(note if box is level and distribution to cutlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): No ca�v� PUMP CHAMBER: (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: 21 U-d. Owner. /f, Date of Inspection: f S=e,'3 SOIL ABSORPTION SYSTEM (SAS): e' (locate on site plan,excavation not required) If SAS not located explain why: Type ►, leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 1.s ?' �7;,a1 r J7�._ -h."f ( J.�(� 171�b i✓ ��ru s -Z CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: " Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NO..,..'FOR VOLUNTAMtY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAI,SYSTEM INSPECTION FORM PART C t SYSTEM INFORMATION(continued) Property Address: ?_3 G�.��/t d IVI s dG y / ;e:�-:vr; Owner: i?a r�Y Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. f� • /3 r s� � y y 1� Page 11 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPQSAL SYSTEM INSPECTION FORM . PARTC SYSTEM INFORMATION(continued) Property Address: ?3 Owner::, j.r,. Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water z o, i feet Please indicate(check) all'methods used to determine the high ground water elevation: Obtained from system design plans on record'-If checked,date of design plan reviewed: Observed site(abutting property/observation,hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-'(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: ✓ �> l .i v Alt r+'1 + ad jkA� Town of Barnstable Health Department 29 --2- 3 O o 367 Main Street, Hyannis, MA 02601 sw. Office 508-790-6265 Thomas A. McKean FAX 508-775-33414 Director of Public Health March,4 4,1996 1 Robert Wolfinger 23 Uncle Willies Way Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE H MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 23 Uncle Willies Way, Hyannis was inspected on March 12, 1996 by Christina Kuchinski, Health Inspector for the Town of Barnstable because of a complaint. The following violations of the Town of Barnstable Rental Ordinance Article 51 and the Sanitary Code H were observed: 410.602 D : Dog feces observed on the carpeted hallway near r rooming units. 410.351: Heat source in bathroom did not have protective cover i The tenant stated she is not allowed to use main entrance light fixture (located at the side of the house facing Uncle Willies Way) to provide for safe passage. Also, the tenant stated that landlord places all of his used toilet paper in open wastebasket in common kitchen. In addition, the tenant stated that landlord cleans his dentures and spits into the sink in the common kitchen. You are directed to correct the above listed violations within seven (7) days of receipt of this notice. . Y ' You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, this violation must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OF THE BOARD OF HEALTH /�!�K Thomas A. McKean Director of Public Health cc: Marjorie Williams i �'FoRmw Hoeesa WARREN,INC.NOV.1979.1983 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L -`�nJ' e CITYlT1OWVN, b DEPARTMENT o, � ADDRESS Cj D _b s)(o, TELEPHONE Address 6,U, Occupant tM Qr 1 R Floor ApaMeftbh ' No.of Occupants No.of Habitable Rooms No.Sleeping Rooms 0144T No.dwelling or rooming units No.Stories�_ Name and address of owner- (c' pl-� )o rn -2 U K r tp w i � l ca s W Q-NGjI.{' Remarks Reg. Via. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: 10-c) Dual Egress:and Obst'n.: ❑B ❑ F ❑ M Doors,Windows: +r'e.L �f v p j y, y CID PM Roof ,,:i r4hj, &-er- Gutters, Drains: 01 5n its 1DIAcGupbt Walls: Foundation: p p7 1 Chimney: r-00Vf- a BASEMENT Gen.Sanitation: A_.?J 64(-,� at, Dampness: t (A 1c 1 Stairs: fA e,,(-4Y- t�►C� Lighting: 0 " ,,r STRUCTURE INT. Hall,Stairway: / ) , ' Obst'n.: f Hall, Floor,Wall,Ceiling: b '4 Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels,Meters,Cir.: ❑ 110 ❑220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: e DWELLING UNIT Ventil. L to . Outlets Walls Ceils. ' Wind. Doors Floors- Locks Kitchen i Bathroom .' Pantryf Den Lhdng Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facll. 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: ress Dual and Obst'n: General Buildina 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 PENALTIES OF PERJURY." INSPECTOR TI� 3 v AM DATE DATE 3 " �-Z ` TIME �P.M.) A.M. THE NEXT SCHEDULED REINSPECTION P.M. c r 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 C.*1R 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D) Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253(A), 410.253(B) and the lighting in common area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. .(F) Failure to provide a toilet and maintain a sewage system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (GI Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to comply with the security requirements of 105 CMR 4110.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602 which results in any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of lead-based paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. (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 dafety. (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 facilities as are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (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 operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. (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, gas-fitting, or electrical wiring standards that do not create an immediate hazard. W_ failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition 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. Z. 348 651 062 Receipt for Certified Mail Ivy No Insurance Coverage Provided N1RE�M,es Do.not use for International Mail GOSTIIL SERVICE (See Reverse) T Sent 741 > Street ar}Q No. - 2 `J! l0 P .,S e and IP Code O 40 Postage M E Certified Fee O LL Special Delivery Fee R'e'sti.Pcte<fiD�titreryyF�e: R�nlrn�Re�'eipTtS'howingi. I to Wfiom&Date Delivered M1 n:? Return Receipt Showing to Whj- Date,and Addressee's Addres TOTAL Postage &Fees Z , Postmark or Date v5 STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). 1.�you want this receipt postmarked,stick the gummed stub to the right of the return address [4. ngrthe receipt attached and present the article at a post office service window or hand it to rural carrier(no extra charge). I. �you do not want this receipt postmarked,stick the gummed stub to the right of the return � ess o�he article,date,detach and retain the receipt,and mail the article. � t you want a return receipt,write the certified mail number and your name and address on a m n receipt card,Form 3811,and attach it to the front of the article by means of the gummed if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT UESTED adjacent to the number. tb you want delivery restricted to the addressee,or to an authorized agent of the addressee, Co rse RESTRICTED DELIVERY on the front of the article. E `onter fees for the services requested in the appropriate spaces on the front of this receipt.Ifun receipt is requested,check the applicable blocks in item 1 of Form 3811. ave this receipt and present it if you make inquiry. 105603-93-13-0218 SENDER: M ■Complete items 1 and/or 2 for additional services. I also wish to receive the H ■Complete items 3,4a,and 4b. following services(for an y ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. � oAttach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address L) permit. d ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N r ■The Return Receipt will show to whom the article was delivered and the date a delivered. Consult postmaster for fee. .� 0 v 3.Article Addressed to: 4a.Article Number a0i -,6� -7 /7 ` 2 7� 2c E 4�yS vl Type '�` Gam!/ 9'Registegd Certified I N '� ❑ Express IVEiil ❑ Insured y aWt -rgetuReceip�for Merchandise ❑ COD U00 r�?Date of Deli bry Z ,r S 1L Au 0 s '5...Rbceived By: (Print Name) \8.Addre e s A dr ss(Only if requested W and fee is paid) t ¢ H 6.Sjgnature: ( ressee or Agent T X (� W PS Form 3811, December 1994 Domestic Return Receipt 1 First-Class Mail UNITED STATES POSTAL SERVICE Postage&Fees Paid USPS Permit No._G-10 • Print your name, address, and ZIP Code in this box A A Healt h Department Town of Banftblo P.O.Box 534 Hyannis,MaMchUSM a= Fax(508)775-3344 Phony(508)790-6265 r FOF3 '/� v D TE' TIM • � P.M. r' y`� IVI: I PHONE AREA E NUMBER .EXTENSION . t.�... ME. AGE 3 , Cit{xA ��. YdIEI LSIGNED - TOPS FORM4003 O` --� . 7 LOCATION j SEWAGE PERMIT NO. 11.i de VILLAGE INSTALLER'S - NAME & ADDRESS i Job /7 B U I L D E R OR OVU ER' DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Z419zle A"i0G ff 1 t'� - r L �--- 3 1 j'V � - � � ,� y ,� � � � 6 `'�sl i - �y� � �� � � � � �! ,� 1 r .�a �S r ✓... Frs............... ...... THE COMMONWEALTH OF MASSACHUSETTS � BOARD OF HEALTH Q.Ll7.lJ....................OF.....T. A17a.C. ................................. JJ AppftrFation for Uispaa�af Works Cfnntitrurtion Prratit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal -L3 .............................(.. ... . ............ Location-Ad Wes, or Lot No. --------- - ..... �7� .. ........ .......................................... ----------------------------------------- Owner 1 Own /I Address a ---------------------------- �� .... A t . ...................................... Sk.•e- Installer Address q 7 d Type of Building Size Lot...'!_3.1_1.�_I__ K�....Sq. feet U Dwelling No. of Bedrooms...............3-........_ .....Ex anion Attic g— p ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons.......__................... Showers ( ) — Cafeteria ( ) dOther fixturss •-------•----------------------------•----•••---------.-------------------•-•-•-•------- ............................................................. W Design Flow................S.!.... gallons per person per day. Total daily flow...................._ S.0 .......gallons. WSeptic Tank—Liquid capacity i2 .gallons Length................ Width..____...__..._. Diameter---------------- Depth................ x Disposal Trench—No. .................... Width..........a......... Total Length....... _.�.-_....Total leaching area... ____._ sq. ft. Seepage Pit No.............�...... Diameter------------�... Depth below inlet......_.-...... Total leaching area__ �.sq. ft. Z Other Distribution box 64,) Dosi tank )a . � _________ � Date._._______ .Percolation Test Results Performed by k- m . a Test Pit No. 1----- .minutes per inch Depth of Test Pit------t -_•- Depth to ground water...... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.__._..............____ P4 •---•-•-----•------------------------------••------------------••-------._..........--....---................................................................ 0 Description of Soil................... ....... ........r------------ .............(�.... .... ............�. .................................. U .............. .....----- - ------ w x -------------------- ----•------------•-•---------------------••---••-•-•---•----------------------------------------------------------•••------------------------------------------•-•-----•---------- V Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•---------------------------------------------------------------------------------•--•------=-=-----•--------- .--------------------------......-----------------------------=................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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..63a T�,.� ...---- •.... ................................ / Dat Application Approved BY_ r--- ,�• ______________ c ,(�,� t ?.,____-.--. Date Application Disapproved for the following reasons__________________________________________________.......................................... .................. I' ..-----...-•--•................•-....-•--.....---•--------•--...-•••----------------......-----••-••--... Date PermitNo......................................................... Issued....................................................... Date ,a 1'No. •--- FEs........`�1..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH r.._l. h ................OF......::?l....i'�.......... Appliration for Disposal Workii Tvitatrurtion JIrrutit Application is hereby made for a Permit to Construct 0� or Repair ( ) an Individual Sewage Disposal System at: .................„._...x........:=.... .....................� l .. .J.._._...................... Location-Address• _ or Lot No. ............ 1.3 tss 3 ..i, ............c � C _�.:.�_�� .......... �; W a wner .Ad.dress --•--•...... ..................................... ! .............•------- Installer Address Type of Building Size Lot_;, .......�.........?.....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building No. of persons............................'Showers G4 YP g -------------------------•-- P ( ) — Cafeteria ( ) 04 Other fixtus ---•-------- - W Design Flow...............S. ........................gallons per person per day. Total daily flow....................'�?�?�........gallons. t ,. � Septic Tank—Liquid*ca.pacity�).W..gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. ................... Width.........;.......... Total Length.............I....... Total leaching area.._....._....._....sq. ft. Seepage Pit No-----------........ Diameter...__._..... .... Depth below inlet..... ......... Total leaching area...Z�- Q...sq. ft. Z Other Distribution box (%,) Dosing tank ( ) _ Percolation Test Results Performed by ? 1 `_Y... _f._: 4.._...... � .. - a Date--=------- -- -----`-='---....----.. ,.� Test Pit No. 1.....:-- ..minutes per inch Depth of Test Pit..... _��--......... Depth to ground,water...._."�"":".___.. �Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground;:water........................ ---------------------•------.............---------.......------....---------.....-•----......---............--•---•-•-•------------•--•------.._...----.--•-- O Description of Soil------------------, .:-------...... --••- l �+ st ='��.') . FiC� � f ) I � ����� �Y U •- 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 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. 01 Signed._i.���'��`'1`✓.t!t._�`:: .. ...... a . Application Approved BY �y ,. , ';! .............................• � G . Date i Application Disapproved for the following reasons:-•------------••------•-----•----•---------------------•--------------------------------._...-•---••-----= ..------••----•-----...---•-----------------•--------------••-•------------------•---------•---.....----..__.....•..-----------------------------------------------------------------------•••-----_...._ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH .............O F....:.rc�r ,�/, Trrtif irFatr of (90ntplitanrr THI I ) TO CERTIFY Th t the ndividual Sewage Disposal System constructed l or Repaired ( ) bY......•--•...� ------------------ --------------------------------------------•.............. ........................._.................. w Installer at................ -•�-.......... �1�e 1/4----- ....... --------,►4-4"--2...................................... ............... has been installed in accordance with the provisions of T -LE 5-Of The State Sanitary Cod as escribed in the application for Disposal Works Construction Permit No._ �C "'.. ................... dated_- -"'___-____-_--•_------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...............................................................•--------•----_.. Inspector.................................................................................... THE COMMONWEALTH.OF MASSACHUSETTS BOARD O HEALTH No.. .......... .... FEE........................ Bistro Works �onotrnrtion ermit y� ..mow Permission is hereby granted.... r. i........ ---------•--•-----•-•-----•-------•-------------------------------•--................. to Construct or Repair. ) a Individual S gages,Disposal System Stre as shown on the application for Disposal Works Construction. rmit Nor2.-?3._.. Dated'" _ /.. .............. �.. .. -= ............................................ , oB and of Health DATE.............. - ----- -.�'�--.-------------•-------•----•--•---- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS µ STWDZODA& 98.5 tadll.�! Ftrow .. Ilo x 3 . �c?p G.pb. M^99•Q A'xP r, �F�rIG •T'L1IG t 330v Ir7G �� • �'7 6.P.D. �A ` � U S� t c500 4SAL. ,-11 . I4 sPosn�- PIT ups= l O� ten,_. .; � � � � iho� r• • . TOTAL '17ESI6►J o .125 G-pD• I 'roT,41_ t.,Ow t 33D 6.P.D. _ .. . . . . Mcc-OLdT100 Qk,-M : CIO 2MI1J• olz IF-SS. �. � 'ram`� � -"- •,.{' i TOIL FNP 100.pILJV ' gQ Loam t ��p,,De t o0o I►N I i ' • sys6a►4 PIPE- 2. `Box 9G.G SEQTfC 10 A. � 12 ��'�: `• FIT el Ail . Ct~CTIFlEL7 PL C>-r Pczot�1 l_ LoCAT o" ,I�y A 32 T k AT T N �vr u-i IJ.(�, 5�oru►J p�--A�.J R L-F ctZE t.l GE t1t:Ql_c�1.1 GCaMPL�IS W ITN TP A1.tta 'SCTC�AGIC �;Cc�U1s;EMC:uTS O1= TNT .. -Toww ot= 13AI2.I,7TA6LZ A►4t) t 0or P�.aN t l . Svt•4�1 ' 'CtZee.�1 LoG,4TEb. W 1"Tti-ll 1.1 T F D PL-Ai 4.1. '�ta'(��TJ �1Zt�rV1S6'D' F�3i �O r ��1(0 6 A YTM$Z. ✓� t;"�`+ r, ,�e..•--• 12[GISIt:.t:ED 1-A�.IG riUe.VcYu�c •t-t-lts h��N ice, uoT ZAScv V►� A.4J 05TC��/1L�G t� l�(ASS. IW,;reL)Mc-w; /,Uc:•1c,( ,� ,"lAcr_ 01:1: APPLAC-&"•r , . �...- nr._ f f�_t-n ri•� t�c*�rr:LM1*!i_ �..DT ` (_INS`✓ __ �)};:rj�" Y�//�I�l�s�.