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Home My WebLink About0019 CHECKERBERRY ROAD - Health F CHECKERBERRY ROAD=269 - 178 annis i 0 'o r Da :x•�tS1r3 4 43—�2-2D� 1 2%37 .e BARNSTABLE LAND COUNT REGISTRY R--EID 1 STRIC TION WHEREAS., peter 'B:. Field of (ames name) 19 Gheake'berr ttoad H .Innis., MA 02601 MA (eddrpas) is tha owner of '19 Checkerberr Road - ` located . (address) , at Hy$.nn � MA_026O1 and Registered with the BarnstableRegisty of Deeds MA(hereina&r referred to as -Lot 67 on_,Land Court Plan 22,$25-P. (Sheet 2) and being shown o�a plan entitled "Subdivision of Land in Barnstable _ �YA, PMertyaf Peter B. Field et al, andm x' s _ dcily,recorded in Barnstable County Registry . Of . .. ti Deeds in (plan Bi ok , Page ; Or on Land Court Plan Number 22825-F (Sheet 2) WHEREAS,:: 'Pacer, >!i aid as the owner of said lot has agreed with the Town of.Barnstable Board of Health to a restriction as to the number,of bedrooms which caai be included in any home built on said'lot as a pre-oohdition to obtaining.,a disposal works construction permit in canV lance with 310`CMR 15.O00 State Etivironmerft Code, '111413 V, IVINnium Requirements for the Subsurface.Disposal of.Sanitary Sewage; r WHEREAS 'the Town of Barnstable Board of Health, as a pre-c ondolion,to granting a disposal works corowdon permit fora selytic system in comOiance with 310 CMR15.200, State Environmental Code,Title V, Minimum Requlrerrtents for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building,permit for the construction of a-single f imily home on : .this property, Is requiring that the agreement for the restridlon on the number of ' bedrooms in any house emstfucted on the lot be put on record with the Barnstabla Count'Registry of DeWs by reco rding this document, . _. u 1 G� NOW,THEREFORE, Peter 5. Field does hereby place the (ownees name) following restriction on his above-referenced land in accordance with his �aetikb Tn ,whieh fegr4ct rrst all run with the land and be blinding upon all,suocessors in title: 1, 19 Chockerberry Road, Hyannis,MA May have constructed (address) upon the lot a house containing no more than 3( ) bedrooms. Peter B. Field agrees that this shall lbe.permanent deed (awmes name) restriction affecting_located on MA, and being shown on the plan recorded in Plan Book_;, Paged Oron Land Court Plan 22825-P _(Sheet 2 For title of Peter b, Field seethe following deed: Book._ , Page Or hand Court Certificate of Title Number #193550 Executed as a sealed instrument day of_.,_P Owner's Signature Peter B. Field Crnmer's signature Owner's signature COMMONWEALTH OF IMASSACHUSETTS Barnstable, Coun ,y . Mauch 21 2D L 1 '. There personally appeared the above-named Peter B. Field known to me to be ft person who executed the foregoing instrument and acknowledged the some to be h i s F free act and deed, before me, `t N ..Wry�n ear on Notary �m z z My com is a Ires: , B/�4Y20?2 (date) ' PUS .. BARNSTABLE REGISTRY OF DM 6� UA-- s�e>2 CD tf L cL p � � I a � �� '� � � � �� l N -� � TOWN OF BARNSTABLE . rr li LOCATION 1� Cft�f.��-�{.�v (L4 SEWAGE#2-00 9- I ZI VILLAGE N>.� n l ASSESSOR'S MAP(& Sl- +PARCEL `� - j3 - INSTALLER'S NAME&PHONE NO. ICI f d SEPTIC TANK CAPACITY AP- )V.1 16,0!a LEACHING FACILITY:(type) Q-6Awt. (/7 (Z xZ- NO.OF BEDROOMS 3 OWNER `S-rapfe Td PERMIT DATE: COMPLIANCE DATE: Separation.Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) �/' feet. Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). IV 4 feet BY 'FURNISHED I Q ,9� �. °gip �' � �o001 No. ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftPlication for Bisposal *pstrm Construrtion 3permit Application for a Permit to Construct( ) Repair(.A) Upgrade( ) Abandon( ) []Complete System XIndividual Components Location Address or Lot No. 1 Owr: 's Name,Address,and Tel.No. ��-•�r�c-pq- J��o CeJ�o� Assessor's Map/Parcel 26 q ✓� �,,�e_.S-7 g lA Installer's Name,Address,and Tel.No./&x,SGre i&/ A✓e"'A-4vcy Designer's Name,Address,and Tel.No. !90.3c.6 6 g z6io 3e zoo a eq 57 S tr, 1Ch. �'33 L 7 7 94 Type of Building: 'Cc S' 10-1 Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) U gpd Design flow provided 3—y gpd Plan Date' --a 9 Number of sheets Revision Date /7 d Title Size of Septic Tank exe_, 7- (OO ® Type of S.A.S. X G Description of Soil }'--ems.(P/A-,_I Nature of Repairs or Alterations(Answer when applicable) /Q-e.,e14CQ. 'cr Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board ealth. Si i Date 5 `t A 9 Application Approved byt)— Date 5 - 1-07 Application Disapproved by Date for the following reasons c Permit No. a a l ' �� Date Issued a.�l^ ...-•,,..r^...:.,..v....+i+w....+i-aww.w✓aK.:+.war*�+S;+frri-*�'^"^"_.y-..vow.+.-,i..'+�-+rv;,ryf. "'i"^'s"....,K�:.-` w',.y.._ _ .�"1►�.� .. ....{..:... .......r.�..,r". _. . . • a-o°�_" ��.' � .,;' , ate..., Fee THE COMMONWEALTH OF MASSACHUSETTS _, Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitatiott for 3pis oral 6pstettt Construction Verm' it Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ") ❑Complete System Individual Components Location Address or Lot No. 15 e• e�c e d� c y�'c Owner's Name,Address,and Tel.No.. Assessor's Map/Parcel 2 v S i b /,-e- Installer's Name,Address,and Tel.No. .-,y Designer's Name,Address,and Tel.No. -ems lFd�' Zora �'c,s� s'�>,�,.�;IA 3 zi 77 Type of Building: Dwelling No.of BedroomsT Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) + Other Fixtures Design Flow(min.required) 0 gpd Design flow provided - y gpd Plan Date Y- 0 5 Number of sheets / Revision Date /1 J-,/ c-- Title ' Size of Septic Tank' f r 5 r /oo c� Type of S.A.S. �l�'h /-be . rc 6 Description of Soil ;p-� Nature of Repairs or Alterations(Answer when applicable) C-C, r �e a eq C r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place-the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si ned " �--- Date Application Approved by c 1(4 Mpla Date Application Disapproved by Date for the following reasons Permit No. 02 C.0 t ! Date Issued S" I o THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X Upgraded( ) Abandoned( )by /'D ll5r<e u IA7-1 ,f-e c- at �fn C G/�PrdaCr-�i 11�/In.`S' has been constructed in accordance G with the provisions of Title 5 and the for Disposal System Construction Permit No. a00 (a dated t D f Installer ? -1 Designer () c P� ui #bedrooms Approved design flow .<;3d and The issuance of this p/e�}{it shall not be construed as a guarantee that the system willdfunction as designAed. Date f l(!()"t Inspector Vl(/�, /L�S- c _ f - -- ------------ ------- --- q ) -----�---------------------- --•----- No. Fee ----=------ C f rz ( r� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Vsposal 6pstem Construction 3permit Permission is hereby granted to Construct( ) Repair( x) Upgrade( ) Abandon( ) System located at l e 4 ��C. ✓ ,,CIslt i .5 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit_(—�,. Date O Approved by U t Town of Barnstable P# . Department of Regulatory Services wuvereer a Public Health Division Date t639. �e� 200 Main Street,Hyannis MA 02601 hffi Date Scheduled D Time - Fee Pd. - OK� Soil Suitability Assessment for Sewage Disnosal 0 � Performed By ` B. Witnessed By: 100� rd . 1 LOCATION & CENT INFQ10"TION Location Address Iq � Owner's Name Address - S Assessor's Map/Parcel: Engineer's Name, NEW CONSTRUCTION REPAIRj Telephone# 0 Land Use _W'e-5110f I l $lopes(%) a Surface Stones Distances from: Open Water Body�_ft Possible Wet Aiea ft Drinking Water Well�� ft Drainage Way ft Property Lrne _.ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes,&perc tests,locate wetlands in proximity to holes) 12 Parent material(geologic) �v '_- %r Depth to Bedrock Ov Q�f Depth to Groundwater: Standing Water in Hole: 1 v____ Weeping from Pit Face --, Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH,WATER Method Used: Depth Observed standing in obs.hole: _ in. Depth to soil mottles: in, e th t w ping from side of obs.hole: In. Groutwwa ustment r _ft• Index WelluMReading Date: Index Well lev Adj.faatdr Adj,Groundwater Uvel G P-RCOUTION TEST Time Observation Hole# "' Time at 9" If Depth of Pere �r Time at 6" Start Pre-soak Time @ Time(9"-6') ~ End Pre-soak Alm/ Rate Min./Inch. Site Suitability Assessment: Site Passed ' Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\,SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistenc '%Gravel O-Z 6it 4�c ' " Z DEEP OBSERVA,TON HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Grave] Z�'Z 2v f� !js /D e� LS a ,e_6 C 6F& . W Aq DEEP.'OBSERVATFON HOLE LOG Hgle Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling _ g (Structure,Stones,Boulders. �. Consistency %Gravel DEEP'O$SERVATION HOLE:LOG Hole Depth from Soil Horizon Soil-SI' ture -Soil Color Soil' Other Surface in. ( ) (USDA) (Munsell) Ivl4ttling (Structure,Stones,Boulders. Consistency, o Gravel) Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes. Within 500 year boundary No 1Z Yes- Within 100 year flood boundary No Yes 1 ' Death of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervi0Q.9, material exist in all areas observed throughout the area proposed for the soil absorption system? ,� If not,what is the depth of na urally occurring pervious material?— —4A Certification I certify that on LC) (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performed by me consistent with the required training,a rti an p rience described in 310 CMR 15.017. Signatu a Date 200 Q:\SEPT"ERCFORM.DOC I __ i pF T Town of Barnstable Banistable AVH� Z� m saGity Regulatory Services De art a g Y A ��90BA 69: 04 Public Health Division ArFb MA'f/ 200 Main Street Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thornas A.McKean,CHO CERTIFIED MAIL 7007 3020 0001 3429 7953 March 20, 2009 Patricia Oliveira 25 Derby Way Barnstable MA 02330 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 19 Checkerberry Rd., Hyannis was inspected On March 18, 2009 by Jaime Cabot, R.S. 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 410.300 & 310 CMR 15.00—Sanitary Drainage System Required. Observed four bedrooms within home when septic (permit#92-436) 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. The following violations of the Town of Barnstable Code were observed: 170-4— Certificate of Registration. Property is not registered with Town of Barnstable Health Department. You are directed to correct the violations listed above within thirty (30)days of your receipt of this notice by removing a bedroom by creating an opening 5' wide between the two bedrooms on the second floor. You are required to obtain all necessary permits prior to doing this. 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 TH!E BOARD OF HEALTH Thomas Ac' eaCA�1 `-- Do`r of Public Health Town of Barnstable Town Of Barnstable SHE h5. > Taw Regulatory Services *. Thomas F.Geiler,Director + sARNSTA�BF:E, a Public Health Division rFp ,A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: vbJ U7) Z00 Designer: J�y �' "" `� Installer: �SF� '� _ Address: . Address- On ��` was issued a permit to install a (date) (installer) septic system at -9 . .,based on a design drawn by (address) dated 5 y Z�. (designer) I-certify that the septic system referenced above was installed sub stautiall according to .lie design, which may include minor approved-changes such,as lateral relocation of the di f ffibution box and/or septic tank. _Zcertify'that the septic system referenced above was installed with'ina c for hanger 0'. greater flign'l 0' lateral relocation of the SAS or any vertical re aaatioir of any component. of the septa ,system)but in accordance yy��'th State &Local IZegiilatons. Plan revisiozx or certified as bixf t ,y designer to:follow.(<5E7 11 t:. t ,07EV Mqs � dAVID (Ins all r s S' are) lViASUN NO FQ1,TsR�C s�tilr-AAUP (I3 er s Signature) (�s,f er'.s Stamp Here) PLEASE RETURN TO BA 's R. E PUBLI,C=HEALTH DIYISIOlY. C I�TiFI.0 TE OF. COMPLIANCE WH t 'Nt3'T.ZEE``:SSUED BOTI °3' ][ FfIR1Vl I3UiLT I;A2D AR1,RECExYED l3}Y 7f`lE BAR. STABLE Y'UBLIIv BQE '> DIVISION THANK,YOU. b f s Q:HeaA/SeFtic,Designer Certification Form g r _ Town. of Barnstable Barnstable �pFTHE Tp� - ~ A[-Ammica City Reg us Department latory Service n.Fz�S-raute,l: o�N639-- Public Health Division x m \---- 200 Main Street, Hyannis MA 02601 2007 Office:.508-862-4644 Thomas F.Geder,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED NIN-1 7007 3020 0001 3429 7885 February 27, 2009 Patricia R. Deoliveira 19 Checkerberry Rd. 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 19 Checkerberry Rd., Hyannis was inspected on February 25, 2009 by Jaime Cabot, R.S. 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 410.600- Storage of Garbage and Rubbish: Rubbish and Debris was observed in the back yard. w vaY2 ? o �l -1 105 CMR 410.500—Owners Responsibility to Maintain Structural Elements: Large holes were observed in the wall separating-t1w garage from the basement. 105CMR410.501 (B)—Weathertight Elements: Door to the exterior from the garage was broken and had gaps exceeding 1/16 inch around frame. �a /1cc�sS .105CMR410.482- Smoke Detectors. Battery notpr Wed for smoke detector and no carbon monoxide detectors were provided for the dwelling 105 CMR 410.501—Weathertight Elements: Garage window is broken. 105CMR 410.351-Owner's Installation and Maintenance Responsibilities: Electrical outlets are missing covers. 105CMR 410.190- Hot Water: The temperature of the hot water was observed at 160 degrees F. The following violations of the Towi of Barnstable Code were observed: . 1704— Certificate of Registration. Property is not registered with Town of Barnstable Health Department. 353-1-Nuisance Regulations.No water proof and rodent proof containers provided for N rubbish. 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 and removing the rubbish and debris from the exterior of the dwelling. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by registering the rental property with the Town of Barnstable . Health Division and by repairing the damaged door in the garage, repairing the damaged wall in the garage, replacing the glass in the broken window and installing covers over the electrical outlets. Setting the temperature of the hot water in the dwelling to between 110 degrees F. and 130 degrees F. 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 sp ak with the inspector who performed the inspection. PER ORDER BO RD OF HEALTH Th as ean, S., CHO Director of Public Health Town of Barnstable Ln r. CO CO rt OFFICIAL USE o^ ru sr N Postage $ Y rnA Certified Fee (r g9Mark O Return Receipt Fee are y p (Endorsement Required) C3 O Restricted Delivery Fee G N lM (Endorsement Required) Nam , 00 rU s p Total Postage&Fees m sa ntTa'C 1 L�Atj--�------V - A---- - p ... - treet,A3 .No.;..` Q or-- Box No,....!�_ �CtJ�- `►� .......-- ^^ ^ Ciry,State,ZIP+4 Certified Mail Provides: • A mailing receipt • A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail& o Certified Mail is not available for any class of International mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,.a USPS®postmark on your Certified Mail receipt is required. o For an•additioQ fee, delivery may be restricted to the addressee or . addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement'Restricted Delivery'. o If a postmark on the Certified Mail receipt Is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed;detach and affix label with postage and mall. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800.August 2006(Reverse)PSN 7530-02-000 9047 �a FORM30 .\ I_W •HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN = w V%A DEPARTMENT 0 ADDRESS C K9 TELEPHONE . Address�f'` p�►`� ---Occupant 1-2 6 LR-i O Floor Apartment No. 'No. of Occupants � No.of Habitable Rooms Z_-A No.Sleeping Rooms � No.dwelling or rooming units_ No.Stories Z_ Name and address of owner N Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish SJ 92F2 KIA t A, Containers: 4406 Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: -oO,2 a.-) Ili 0 ,(5) Roof w t, i.S Gutters, Drains: L,;rc A.-t�fL'C ir1 Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: tj��"( iw Lc�2• �113 flC/® Dampness: ')A• 6," Stairs: Li htin : a/�-vim r.-Tx .-( u A— �.�£✓L IO ep,Z� STRUCTURE INT. Hall,Stairway: ov Obst'n.: U C> 'G�G� ./L i �?� v Hall, Floor,Wall,Ceiling: U"C A-_i -s [1/ Hall Lighting: e,&V f!J / Hall Windows: i2ov-f rj 44 ! f HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST_ Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAV Panels, Meters,Cir.: ❑ 110 , 20 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ve L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom f M061 Q 110 % Pant 11 r� Den Living Room Bedroom 1 p Bedroom 2 (L Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: c-u<v !J AeZ—S"tA(!>LC Infestation Rats, Mice, Roaches or Other: b 9-0 1 Egress Dual and Obst'n: / '7 t1� 176 General Building Posted U k ST£12to 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 PENALT7�7 PERJ Y " INSPECTOR TITLE A. DATE Z rZ.oQ TIME A.M. THE NEXT SCHEDULED REINSPECTION ��.A j 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 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found tc 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 sufficien-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. i (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254, (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, o-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 orderec by the Board of Health. Citizen Web Request Page 1 of 2 Citizen Request Management - Internal Use Request ID: 24643 Created: 2/24/2009 11:28:30 A Status: Assigned To Staff Assigned To: Cabot, Jaime Health Office Anonymous: Yes Category: Chapter 170 : Housing Overcrowding E.C. Date: 3/10/2009 ! Created By: Parvin, Lindsay Citations: Health Office Time Worked: 1.00 Response Time: 8.00 Requestor Details: Email: Request Location: 19 CHECKERBERRY ROAD Hyannis, Ma 02601 Parcel Number: Map: 269 Block: 138 Lot: 000 Request: Requestor reports several vehicles parked outside residence(six). Requestor suspects it to be a rental with an additional apartment above the garage. Request Work History: Entered on 2/25/2009 1:07:18 PM by Cabot, Jaime JAC inspected property on 2/25/2009 appears to be used as a two family. Owner is a Patricia Deoliviera 774 487-7648. JAC to issue order letter for violations. -Internal Note History: System entry on 2/24/2009 11:28:30 AM: Assigned to Cabot, Jaime http://issgl2/IntemalWRS[WRequestPrint.aspx?ID=24643 2/25/2009 Barnstable Assessing Search Results Page 1 of 2 2009 Assessed Values: DEOLIVEIRA, PATRICIA R 19 CHECKERBERRY ROAD Appraised Value Assessed Value Map/Parcel/Parcel Extension Building Value: $ 124,400 $ 124,400 269 / 138/ Extra Features: $ 5,900 $ 5,900 Outbuildings: $ 0 $ 0 Mailing Address Land Value: $ , , DEOLIVEIRA, PATRICIA R Totals $ 283,900 $ 283,900 19 CHECKERBERRY RD Residential Exemption Received= $100,964 HYANNIS, MA. 02601 2009 REAL ESTATE Tax Information: Tax Rates: (per$1,000 of valuation) Community Preservation Act Tax $ 37.87 Fire District Rates Town Residenti Barnstable FD - All Classes $2.37 $6.90 C.O.M.M. - All Classes $1.08 Town Commen Hyannis FD Tax (Residential) $ 505.34 Cotuit FD - All Classes $1.43 $6.12 Hyannis - Residential $1.78 Town Tax (Residential) $ 1,262.26 Hyannis - Commercial $2.77 W Barnstable - All Classes $2.11 Community Pres Total: $ 1,805.47 Construction Details Building Property Sketch & . Building value $ 124,400 Interior Floors Hardwood Style Cape Cod Interior Walls Drywall Model Residential Heat Fuel Gas Grade Average Heat Type Hot Air Stories 1 1/2 Stories AC Type None http://www.town.bamstable.ma.us/assessing/2009/displayparcelO9map.asp?mappar=269138 2/25/2009 Cabot, Jaime From: Cabot, Jaime Sent: Wednesday, March 18, 2009 1:41 PM To: 'andarilhaus@yahoo.com' Cc: Edson, Linda; Miorandi, Donna Subject: 19 Checkerberry Rd, Hyannis Hello Ms. Oliveira, As we had discussed I'have contacted the Building department regarding your home. Per Linda Edson Zoning Enforcement officer the steps you would need to follow to obtain an affordable Accessory Apartment are as follows. Move back in to the house at 19 Checkerberry Rd. then a verification form would need to be approved by the Building Commissioner to determine that the upstairs kitchen was in existence prior to 2000. Contact Linda Edson in the Building Department at the 200 Main St. office regarding this. Now that I have Inspected the entire house I have observed that there are four bedrooms present in a house that only has approval for a three bed room Septic system given that the property is in the state designated zone II of public water supply, pursuant to 310CMR 15.214 no expansion in bedroom count would be possible unless enhanced nitrogen removal is provided as per 310CMR 15.217. (Zs If you can determine that you have approvals for the 2nd kitchen unit in the Affordable accessory apartment, a two compartment septic tank or two septic tanks in series would be required as per 310 CMR 15.223(b). Please do not hesitate to contact me if I can be of any help with this matter. Jaime Cabot, Health Inspector Health Division Town of Barnstable (508) 862-4651 1 . .-.:,-.�-.._-vi:n'.....�-'r^+.<^on,+�•�,�+..t}rv"w+^,,,,.,�n.`Y''+�w.a^°"'"...,c�r+-°L=�.�:f�^^4,;..-�'Y:<.,�-..+a:;,,.�;+r�v.:.�,�•:,K.,_,r ,%v:.. A ,... -•.,f. ,�,,...�:,y.. ,....,... -,. . n TOWN OF BARNSTABLE BAR-w ";5.5 Ordinance or Regulation WARNING NOTICE Name of Of fender/Manager N 0 Li y U dob Address of Offender i 4 •i MV/MB Reg.# Village/State/Zip .5 ) S S# Business Name , po am/pm on /. 20L7 Business Address Sign`tature of Enforcing Officer Village/State/Zip '*� � 4 acs MA toot Location of Offense ,t'zr. fL 4 a� Zt L.t Enforcing Dept/Division w .� A, � ;'� l "' C;'_4�,Offense Facts , .�S h.i3 ` )L i .5 �l"��y`{J.�y �, ,t ti^v#,.�•w t''"3 S. '3 ' . i'F-B This will serve only as a warning. lAt this time no legal action has been taken.( It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD.ENFORCING DEPT. FORM 30 C&W HORRS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN 0 DEPARTMENT 21�v MACH SZ• _ IrA S b2�o ADDRESS TELEPHONE Address Al-►\-kkb A n UvVt Occupant VA�W7 Floor Apartment No.--- No.of Occupants _N,A- No. of Habitable Rooms Z No.Sleeping Rooms No.dwelling or rooming units No.Stories 2- Name and address of owner A C�'A- d t, t f-r YLA gT.fo If- IW� C>z Remarks Reg. Vio. YARD Out BIdgs.A Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: IF Stairs: Lighting: STRUCTURE INT. Hall,Stairway: S S Obst'n.: Hall, Floor,Wall,Ceiling: P_C N Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair Vv t> t%,7 6 LO gY5 TYPE: Stacks, Flues,Vents: S-4- -Cc C, S S'U:M v� CSC PLUMBING: Supply Line: t 2- Z t4 -CChE12 S - ❑ MS ❑ ST ❑ P Waste Line: & 1?_r, S A. 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 Z Z Z Bedroom 2 Bedroom 3 1 Bedroom 4 S,,5- St= Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted "-C rJ S"t 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 O P�. INSPECTORTITLE �..S��c,-tvit.._ A. DATE 31__ TIME �U �� P.M. A.M. THE NEXT SCHEDULED REINSPECTION T- �'' P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to ex st in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in-his listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness_ which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfittina, 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, cockroacf es, 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. f 1 COMMONWEALTH OF MASSACHUSETTS �\ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 19 Checkerberry Road Hyannis MA Owner's Name: Paul Norman Owner's Address: Same Map:/269 t Date of Inspection: December S. 2000 Lot: 113 Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 � Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my disposal training and experience in the proper function and maintenance of on site sewage g p osal 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 N urther Evaluation by the Local Approving Authority Fas Inspector's Signature: Date: December 8, 2000 The system inspector shall submi 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. r Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Checkerberry Road Hyannis, MA Owner: Paul Norman Date of Inspection: December 5. 2000 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: .✓ have not found an information which indicates that an of the failure criteria described in 310 CMR Ia y y 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 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 ' Y r Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Checkerberry Road Hyannis, MA Owner: Paul Norman Date of Inspection: December 5, 2000 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 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of 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 K OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Checkerberry Road Hyannis, M4 Owner: Paul Norman Date of Inspection: December 5. 2000 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than 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. ✓ An portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface _ Y P P P "Y water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply 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: 19 Checkerberry Road Hyannis, MA Owner: Paul Norman Date of Inspection: December 5, 2000 Check if the following have been done: You must indicate`yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner;occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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 CUR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 Checkerberry Road Hyannis, MA Owner: Paul Norman Date of Inspection: December 5, 2000 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 1999-82,500 Qals.;2000-84,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/MUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gTd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: May 31194•Mar. 10199-per treatment plant Was system pumped as part of the inspection(yes or no): 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 known)and source of information: Sep 16192-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 i Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 Checkerberry Road Hyannis, MA Owner: Paul Norman Date of Inspection: December S. 2000 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC .TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _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: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping every 3 years. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 Checkerberry Road Hyannis, AM Owner: Paul Norman Date of Inspection: December 5, 2000 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: -- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The box was not dug up There were no signs of failure in the leach nit PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 1f Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 Checkerberry Road Hyannis, MA Owner: Paul Norman Date of Inspection: December S. 2000 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I-6'x 6'with 2'of stone Per as built card leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit had 4'ofwater on the bottom The scum line was at the same level. There were no suns offailure. The cover was 2' below grade The bottom to grade was 11' CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 Checkerberry Road Hyannis,MA Owner: Paul Norman Date of Inspection: December S, 2000 Map: 269 Lot: 138 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. aA�k I � O � ,A,_ ace Ql _ ly a Aa- ads A3- 1�{ O 83- asr y A'q- 95' 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 Checkerberry Road Hyannis, MA Owner: Paul Norman Date of Inspection: December 5, 2000 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) ✓ Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the pit to grade was approximately 11'. Using the USGS topographic map and the Cape Cod Commission water table contours map the maps were showing approximately 20'+/-to groundwater at this site. Using the Cape Cod Commission Technical Bulletin the high groundwater adiustment for this site (MI W 29,Zone A 10/00)was 6.3'. The site is approximately 10'higher in elevation than the street. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 s FS Commonwealth of Massachusetts Executive.Office of Environmental Affairs Dept. of Environmental Protection ,John Grad One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 1 813 WILLIAM F.WELD l Governor ARGEO PAUL CELLUCCI ��^�� 1� Lt.Governor f. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION O ,' PART A CERTIFICATION O ` R 'N Property Address: 19 Checker Berry Rd.Hyannis Address of owner: Date of Inspection: 1115197 (If different) Name of Inspector: John Graci Eunice Lucas I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) s Cc+ Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the lime of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: This Inspection Is based on crlterla defined in Title V x Passes code 310 CMR 16.303.My findings are of how the system Is _ Conditionally Passes performing at the time of the Inspection.My Inspection does _ Needs urth Evaluation By the Local Approving Authority Bepticpsystemandanyorlguarantee c mp nenttssuseefuulireyofdie Fails Inspector's Signature: Date: 1116197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Collipiiance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127)97) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Checker Berry Rd.Hyannis Owner: Eunice Lucas Date of Inspection:1115197 _ Sew.acie backup or.breakout or high.static water level observed.in'.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled'or replaced The system required pumping more than four 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 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone i of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for'coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: _ 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Checker Berry Rd.Hyannis Owner: Eunice Lucas Date of Inspection:1115197 D]SYSTEM FAILS(continued) Yes No 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revleeA 04R7197( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 19 Checker Berry Rd.Hyannis Owner: Eunice Lucas Date of Inspection:1115197 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: ,c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x _ The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x _ All system components,excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x _ Existing information. Ex. Plan at B.O.H. Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is x — unacceptable)[15.302(3)(b)] (reylsed 04f17R7) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 Checker Berry Rd.Hyannts . Owner: Eunice Lucas Date of Inspection:11r5197 FLOW CONDITIONS RESIDENTIAL: d.lbedroom for S.A.S. Design flow: 3" g'.p' Number of bedrooms: 3 Number of current residents: 1 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(lasast two(2)year usage g (gpd)' Sump Pump(yes or no): No Last date of occupancy: nra COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nre Last date of occupancy: nra OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was pumped last year. System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: rJa TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(if known)and source Information: 1992 I Sewage odors detected when arriving at the site: (yes or no) No treylsed 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 checker Berry Rd.Hyannis Owner: Eunice Lucas Date of Inspection:1115197 SEPTIC TANK:x (locate on site plan) Depth below grade`. 1' Material of construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L8'VH5'7'-w4-10^ Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness:1" Distance from top of scum to top of outlet tee or baffle:S" Distance form bottom of scum to bottom of outlet tee or baffle: IT" How dimensions were determined: Measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound.Recommend pumpinp system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: nra ( lain other Polyethylene_ exp Material of construction: _concrete_metal_FRP_ ) Dimensions: rda Scum thickness:nta Distance from top of scum to top of outlet tee or baffle:nla Distance from bottom of scum to bottom of outlet tee or baffle:rva Date of last pumping'.. Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) We BUILDING SEWER: (Locate on site plan) Depth below grade: t-a'• Material of construction: cast iron x 40 PVC_other(explain) Distance from private water supply well or suction linetown Diameter: 4"— Q,mments: (conditions of joints,venting,evidence of leakage, etc.) (revised WNW) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 Checker Berry Rd.Hyannis Owner: Eunice Lucas Date of Inspection:1115197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: roa Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: n1a Capacity: N13 gallons Design flow: rdagallons/day Alarm level:_nla Alarm in working order? Yes No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) roa DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: ala '4 Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)t! Alarms in working order(yes or no)_Ye: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) rda I (reyleed 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Checker Berry Rd.Hyannis Owner: Eunice Lucas Date of Inspection:11r5797 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number. t,000gallonleachpit leaching chambers, number:Na leaching galleries,number: Na leaching trenches, number,length: Na leaching fields, number,dimensions:Na overflow cesspool,number:Na Alternate system: rda Name of Technology._Na Comments. (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The leach pit la structurally sound and Functioning properly.It had T orwater In It CESSPOOLS:_ (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: Na Depth of scum layer. We Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY:_ (locate on site plan) Materials of construction: Na Dimensions: rue Depth of solids: nla Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Na (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 19 Checker Berry Rd.Hyannis Eunice Lucas 1115197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) a �kc pee�- � A �i O AC QA i Page f o! 10 (revived 0427W) J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 19 Checker Berry Rd.Hyannis Eunice Lucas 1115107 Depth of groundwater 12. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts 11bq• 10 0[ 10 (revised 04)27197) - TOWN OF BARNSTABLE LOCATION �� GGCC� �� SEWAGE # VILLAGE 4tisV1i11S ASSESSOR'S MAP & LOT 01G9 /3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY OTIV LEACHING FACILITY: (type) !' 1T (size) COX/0 NO.OF BEDROOMS n BUILDER OR OWNER ��u� r10eMAll PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili7) Feet Furnished by SVcd-dam � FU d Ci J �[ s J � T � Q' � T `�° cb Q � t'' "► LT c!1 � � TOWN OF E. STABLE LOCATION' / SEWAGE #��=�'/' 'JII.?AGE ASSESSOR'S MAP & LOT INSTALLER'S NAME APHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: • COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching faciliy) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by .,Al 7L ' . E 26 T i f moo! BL S � •a o 'Y G� / i,bl OF fLtr / •::/ S�owir on .1/jr.� d�oi� �� GEORGE yGn J. E.ANIDES •: ;iZ-n�f� f'nne' �SGOD�-DUrj�G ►loaf*Tt3 a� /,7 A- 4fCiSTER � 1 �41 n 4J i17 A wr e P Ae 1 7 WXien RZ 07 PL ,4 /y c'HFc� �Bfe,ey RD La74087 D WNE D B Y i� ,c!an � Cc+u�f SCi4[F � =30 DOG 2, IM SOP, 7- -1,JAI I Dt.3 Q,66 50pyr rot 48 SE-RU.SHA LN. W-YAe14007Nq MAr 4 17, P� e • 40 FnA. s � y -Z, ,bl .r 74 7=.5-6 ter✓ 6+K. ------- - e T o Ire , '.4,J dl"on OEOROE y✓ J. LANIDES H z;n t ;'nne' r`LSGVO/-ouG 5 C NO 22723 ,r 9F�►STER ��•� �u9usf l9 �JB.S � LA • , . ::.%l �7J 7�J1� �-O h/iJ� /a Wt D t"fn� T .4 �afn,sf46/c W�« CoA� 7� jjcrc�,l. P(07 PZ 4/</ �/,c//,s D k/,V E D Y %e cyan (! 2)FC 2► /9,f 4BTERU.SiYA ,LnN. ►M•1"APM007N MA, ti Q �7 TOWN OF BARNSTABLE i LOCATION /09 C-oz�- SEWAGE 4-J VILLAGE ASSESSOR'S MAP & LOTc7Y,,,� -/j- 1' INSTALLER'S NAME & PHONE NO.4?611&—U-0 T` Cti,-Ja ' SEPTIC TANK CAPACITY ul LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER (Ji1/IC /Cd-46 DATE PERMIT ISSUED: � �� x. DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ��i 6� � � n � � � � `y T. x 2 ....N .. .. THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOAR® OF HEALTH �� leConser atp TOWN OF BARNSTABLE ed Appliratiun for Diipuua1 urkii Tomitrurtiun rrmi# Application is hereby made for a Permit to Construct ( ) or Repair 0'e) an Individual Sewage Disposal System at 19 �e...� CW_6 �2, JiV J S --... ------- ......... ......................../--.........---••------•-- ...................................... ..................... ............... Location-Address ......IJiJ�c� G!�C'. s -Sd- 2t� . - ' .. Owner Addres W ... . CG c _ 7105�_ G�,lT i26 . ......................... Installer Address -_� Type of Building Size Lot....Z5,t_l..60..:-.Sq. feet Dwelling—No. of Bedrooms................ ........................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures -----------------------•-..-.-. .. d --------------------------------------•--------------------•------------------- W Design Flow................. .............gallons per person per day. Total daily flow................ ..............gallons. WSeptic Tank—Liquid capacity/ .gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.............`_.... Total leaching area....................sq. ft. Seepage Pit No........./...... Diameter......./ ...... Depth below inlet..... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.................................. --•-----•--•------- Date........................................ ..a Test Pit No. I................minutes per inch Depth of Test Pit---................. Depth to ground water-------.--_.___--_.....- r3 Test Pit No. 2................minutes per inch Depth of,Test Pit.................... Depth to ground water........................ 9 ---•-------------------•----•--•-•-•----••------•--•-----...------------------.........-•--•-•----...-------------•----•--•-------•----.................•---- 0 Description of Soil........................................................................................................................................................................ x U ...............•---•--------•-•---•--•-•--•----•---•••-••-----•--------------------•••--••••...-----------------------•••--•--•••••-•---••-•----•----. ........................................... W --------•--•-----------------------•----•-. -•--------•.-----------------------•-----•--•----•-----------•----•-------------------------•-----•----•------ U Nature of Repairs or Alterations—Answer when applicable-------- /GOq � _Gf !cS?Z/nl� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance b n is b the board of health. Signed ..........,i`........... ------------- .......................... Date ApplicationApproved BY -------------------------------------------------------------------------- ------------------------------------------------------------------------ --------------------------------------- Date Application Disapproved for the following reasons- -------------------------------------- --- -------------------------------------------------------------------------------------- .. .................................. ... ............. ..... ....... ............................. ------------------ ------------------.... ----------- --------- -------------------------------........................ Date PermitNo. .................................................................... Issued ..---------------------.-...---------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J TOWN OF BARNSTABLE Appliration for 11ispusttl Works Tonsirurtiun`Frrmi# Application is hereby made for a Permit to Construct ( ) or Repair (>4 an Individual Sewage Disposal System at ....._... 'owner--es - -- —`._... — -— �'--..—_____......._...—.. or Lot No. _ Location-Address - _____------------- -- - ----- ------ ------ - - ---- --------� l�i �' ----------- ---- - —Addres ..__' --- - - 1� 2� %�i 29 /---S Installer Address U Type of Building Size Lot___ Sq. feet I-, Dwelling—No. of Bedrooms---------------- Expansion Attic ( ) Garbage Grinder ( ) a Other a —Type of Building - ( )g ____________________________ No. of persons----------------------____-- Showers ( ) — Cafeteria d Other fixtures - - -- W Design Flow----------------------�---------------gallons per person per day. Total daily flow---------------- G--------------gallons. WSeptic Tank—Liquid-ca.pacity4� _gallons Length_---------------- Width---------------- Diameter----------------Depth-•_•____-_:_--__ x Disposal Trench—No.___-_-------------- Width--------�---------- Total Length-------------7----- Total leaching area----_------------_sq.. ft. Seepage Pit No---------- Diameter.......AQ_.____ Depth below inlet_----_lp---------- Total leaching area------------------sq./ft. Z Other Distribution box ( ) Dosing tank ( ) �_r Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- P-4 M Test Pit No. 1---_--•______-_•minutes per inch Depth of Test Pit-------------------- Depth to ground water_________--•-_------____ G4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water___---__-__-___----_---_ a -------------------------------------------------------------------------------------------------------------------------------------------__ 0 Description of Soil--------------------------------------------------------------------------------------------------------------- W ------------------------------------------------------- U -------------------------•------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------- _ Nature of Repairs or Alterations—Answer when applicable______� �_______ GoQ Ezf�_______lT -,j d �.5�'j� U eP - - --- �-------------------------------- ------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s been issued b the board of health. Signed---------- v'(_ , :�--.- I �� '------------------_ Application Approved By ---------------------\----------- ------- -....... ------------------- ----- -------------------------------------------------------------------- --------------------------------------- Date Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ ------------------------------------ ------------------------- --------------------------------------------------------------------------------------------- ---------------------------------------- Dare PermitNo- -----------------------------_ ------------------_------- Issued ------------------------------------------------------------------- Dare �-s THE COMMONWEALTH OF;MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (9.ez#ifictt#.e of (gnmplianre THIS IS TO CERTIFY, That the Indivi ual Sewage Disposal System constructed ( ) or Repaired ( �) Z,-7-0 LU r'by Ins�ral'�er4 i�- -�-S-----l-------------------------------------------------------------------------------------------------------- at -------------------- ------------------- --------------- - ` ------------; has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. `_12----_-�) ---------------- dated C_/_)____-S_z--__________.__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAi NT E THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--_-------------=�- � /' �� Inspector ---------------------------------------------------------------- --�_�--------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �---- Dispusttl Works Tuns#rudiun lirrmit Permission is hereby granted-----------------------------Z_�4 G_C'�Z7-__--_-_L-C, J_�_, •-----------------------------•-------- to Construct ( ) or Repair ( ><:)r an Individual Sewage Disposal System f at No----------------------------------------------- --------1 fC/'� f `� f ��-----------�=�---�7 T!�(/!S.t Street 5 , Y� / l !L/9 L as shown on the application for Disposal Works Construction Permit No.__,._----__-I-_---_V- D t d--_-----__/-------------------------- ---------------------------•---------------------------------------------------------------- - 1 2 y Board of Health DATE -- ........................................ FORM 36508 HOBBS ar WARREN.INC..PUBLISHERS ASSESSORS MAP : ( 7 __.. TEST HOLE OGS �� t'�I► FLOOD ZONE: /OT x��,aGIC �L,� SOIL EVAI_UA OR : I �r)�i � 1 t�✓t� WITNESS : V `d 101�'-��"( 1 The installation shall comply with Title V and Town of Barnstable Board of REFERENCE : p� j pL �--, EP7-V L DATE : 1 iL l Icalth Regulations. W - --- - The installer shall verify the location of utilities, sewer inverts and septic °1 `� _ PERCOLATION RATE: .0 Z U �M, I 2'r Y p �f'C components prior to installation and setting base elevations. -- -- I -- -- 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8 per foot. The first _ I TH- I Tli-2� two Meet out of the d-box to the leaching shall be level. I '� t,�( � ___ _ ` 1- v�( �J fl �ps ►M:, �� 4) This plan is not to be utilized for property line determination nor any other IL purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. �11V' fi) Parking shall not be constructed over H l 0 septic components. 1 �� 2 .,�` -- ---- 7) The property is bounded by property corners and property lines. LOCATION MAP 8) The property owner shall review design considerations to approve of total s design flow and number of bedrooms to be considered for design. Receipt '�J of payment for the plan and installation based on the plan shall be deemed ZL) � '� �2- approval of the design flow by the owner. D� �Z 9) The existing; leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall G �^ �, ► ______ ____ 3 be removed along with contaminated soil and replaced with clean sand per 2'1 t` iDCX: -7 Title V specs. t f 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCI-I 40 PVC with ends grouted if 1 1 \ I S E P I IC SYSTEM D E S I G IV applicable. The proposed SAS is being installed below the water service \ ; I line. The line is to be sleeved as aforementioned and maintained in place. � I '\ FL0V ESTIMATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. I 12 T'rl : installer is to take caution in excavation around the gas line. ! , 1 BEDROOMS A7 GAL/DAY/aEDRc�OM GAI./DAY 13 The installer shall verify the location, quantity and elevation of the sewer t ,1(1h �( I lines exiting the dwelling prior to the installation. \ --- I SEPTIC TANK GAL/DAY_. x .2 DAYS GAL - \ \ \- 71 \ \roe' USE 1C}C GALLON SEPT TANK ��l �nwq_. . T \ \ SOIL ABSORPTION SYSTEM H20 AL>6 Pia<' 150 ow I-T:�Z> W/ 00 I S I DE 'AREA: ' \ I BOTTOM AREA 2c, ' �:��>;3� `� 1.� � o � `' ��.1.__...___ J SEPTIC: SYSTEM SECTION 6-kw(a�2 - �5 '/ zoo' ....---- ��/�� ►'1d[r' k �1,h� � L_.__-!� (t�„ti.,_ �.�_ _�� k it ``_` , 1000 GAL <jnil i Z i t / i� q �. a I U f v- I SEPTIC TANK :> i, i _ r_�.� (7 33 SITE AND SEWAGE PLAN I, I -- ---- -- . � '� LOCAT I ON ( PREPARED FOR : ��T21G1A i SCALE : I 2 w DAV I D B . MASON, DATE: '� I N DBC ENVIRONMENT L DESIGNS EAST SANDWICH . MA DATE HEALTH AGENT ( 508 ) 833- 2177 ASSESSORS MAP -- - ZC-'� - --- -- ----- TEST HOLE LOGS ROTES: ti c PARCEL : C r FLOOD ZONE : 1,/67- SO I L EVALUATOR:'JAvig WITNESS : "'W:41A 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: DATE: LG't� � o� pL �� Health Regulations. gb� � ��-- j.��l(7J E5� /z. Z ��'� PERCOLATION RATE : .L Z Ali` I 2) The installer shall verify the location of utilities, sewer inverts and septic ' ,; O components prior to installation and setting base elevations. H-1 H-2 3 All raN,it septic piping to be 4 inch Sch 40 PVC at 1/8" g Y P P P g per foot. The first TH I TH 2 two feet out of the d-box to the leaching shall be level. 4) This p!2n is not to be utilized for property line determination nor an other � Y A lOt( Z ! Z s purpose other than the proposed system installation. Z'J Lv;r�, " bj�eYJ 2 ,�v� �`4�1� 5) All septic components must meet Title V specifications. 1 1$ j ;Lr.� I (� t��' 6) Parking shall not be constructed over H 10 septic components. V _ 2 J� — --- 7) The property is bounded by property corners and proper',,y lines. LOCATION MAP 5 � 8) The property owner shall review design considerations to approve of total r 2�v 6�C' n . t-`°� design flow and number of bedrooms to be considered for design. Receipt I-,- \of pa) ,,>nt for the plan and installation based on the plan shall be deemed �ILIappro�al of the design flowby the owner. �2. Q) TI'.e c 1;:g .cuc.u.g or cesspools shall be pumped and fiiicu wiilr material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per � f 4 � ,��• r� ;'� 11�,1��: � Title 87 specs. \12b,D0 f - - --- _ 10)Systern components to be 10 feet from water line. Sewer lines crossing the 2'Z _ _ water ime sha#I be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPT I SYSTEM DES I G N applicable. The proposed SAS is being installed below the water service line. Tl,c line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists 'i is to be removed and is the responsibility of the FLOW ST I MATE owner to ciisure such. ` ,•� 12)The installer is to take caution in excavation around the as line. �Bk DROOMS AT l �D GAL/DAY/BEDROOM - vAL/DAY 13)The inotalter shall verify the location, quantity and elevation of the sewer lines e thing the dwelling prior to the installation. SEPTI *,' TANK �N I� ?j 3 O C AL/DAY x 2 DAYS - � GAL USE !'? ? GALL ON SEPTIC TANK I ► — ?! �� ! SOIL ,.4SORPT I ON SYS 1-EM _\ � � � I � �� L� �> I-�20 •ADS 1q�LL �O U w CT.� / -- --- - T'<'- r 1 M1 t 1 up, ,., t' i V l/�!-1 le {,f�'�{[J K-A/ (. \ 1 1 DE AREA: t #1 41� X Z X � _ 1�1"� r vr` 1 1 - ` 2 BOTTOM AREA: Z�{ i_Zy _ 3 VVV l -- y, 71 SEPTI SYSTEM SECTION - - - - � _ `\ �- - __ :. l#t��`� ►Whet' i � r ` CN ►� jvtu�� t r ----_-__-� c.,, ��, � � �R5 BbtGtk:- �jp, 2�/�-�,•�57a�1 02 o � BO 10X g ,� p i .o v o o GAL 3DII I Z "� ao- �L SEPTIC TANK 01 SITE AND SEWAGE PLAN LOCAT I ON : �q C1Ci� Q ICJ PREPARED FOR IGIA 5TA-FL'C� SCALE: 30 DAV I D B . MASON,P� DATE: `� 2aJ� DBC ENVIRONMENTAL DESIGNS Z EAST SANDWICH . MA 3 [;ATE E#EALTH AGENT ( 508 ) 833— 2 1 77 Zty.. .. .� .-......LY ..< asuw.•i ....x-rr,., ..,,_...-. _..3!P'._ .z .a-.-._f.u- .._�-.nee- a_ _