Loading...
HomeMy WebLinkAbout0017 CONSTANT LANE - Health 17 Constant Lane c6tuit P 039 067 - -- - - --- -- --- - __ - - Commonwealth of Massachusetts 039-ou-;�- gt Title 5 Official Inspection Form -� I= Subsurface Sewage Disposal System Form ` -Not for Voluntary Assessments 1 Property Address Owner Owner's Name -- ---- / information is ✓ /�� OA 3� . required for every �� _ page. City/Town State Zip Code Date of Insp tion Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. �I� 1513 � Important:When filling out forms A. Inspector Inforgiation on the computer, W 1 Q r/ � i use only the tab 111 (r( ,Q( ` key to move your Name of Inspector -� cursor-do not �/04 o ! �� use the return Company Name 190 �O 4 U� k�ey.Q a Company Address City/To State Zip Code S�3�So — 90 � �zl Teleph Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the s 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7400'� _ l Inspe or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7f26/2018 Title 5 Official Inspecbon Forth:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts I? Title 5 official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name / information is required for every 1111 page. City/Town State Zip Code Date of In ecti n C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System P es: I have not found an information which indicates that an of the failure criteria Y y e a described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System•Page 2 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form �IbJ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� Property Address Owner Owner's Name information is �•fl required for every O4(i18 � page. City/Town State Zip Code Date of Insl6ectiofi C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): m required min more than 4 times a year due to broken or obstructedpipe(s).The ❑ The system equ ed pumping g y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ter, Owner Owner's Name C / /yj D� information is // required for every page. City/Town State Zip Code Date of I p C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El due or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool , 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v Property Address Owner Owner's Name information is 6W(4 � A4 0. C: A(/C;X required for every page. City/Town State Zip Code Date of lnspecticfh C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ E1000, Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ 20 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 21"0' Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or u tributary to a surface water supply. ❑ �/' Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ [ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes'or"no"to each of the following, in addition to the questions in Section C.4. 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 t5insp.doc•rev.7/26/2018 Tide 5 Ofriciai Inspection Form:Subsurface sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 1 (4ins'Ta L,(� Property Address Owner Owners Name/'O�u r� /J9,4 063S information is ll.� /i required for everyP -1-/ page. City/Town State Zip Code Date of Inspect n C. Inspection Summary (cost.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for aH inspections: Yes o ❑ 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? ❑ as 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 Izavailable 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? z Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)1 t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Cal V1 j Owner Owner's Name a information is l ' required for every d fit 1-� 0.63� page. City/Town State Zip Code Date of Ins ectio D. System Information 1. Residential Flow Conditions: .3 Number of bedrooms (design): — Number of bedrooms(actual): 3 3a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Qd0 r_ _ � �-g ��e� 6 m�c� / a N �✓ /s0 a SOO C4ovtwirf w Yer � Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes L" No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes R---No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface sewage Oisposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 7 u Property Address a 2� Owner Owner's Name ^ information is CA41�- � �. a 3Srequired for every 'L page. City/Town State Zip Code Date of Inspectfort D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq_ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: 3 6w+�✓ 2•�j Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp•doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / 7 C0414q04 Property Address Owner Owner's Name / information is e 1 �/� required for every K�T /`/ page. City/Town State Zip Code Date of Ins ecti n D. System Information (cost.) 4. Type of Sy Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system.(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under'contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: TgwL"' VQ%scnd)L_ /lbw S� ,Q.S 01c0o Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;'40 El cast iron PVC ❑ other(explain): t Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form�W4- -Not for Voluntary Assessments / ( C044.r : �N Property Address Owner Owner's Name information is .- /J OZ required for every - 4(.4 I �! v d-� c'Z/' page. City/Town State Zip Code Date of Ins ecti n D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet Mate ' of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 0/4 ems« Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): f/llt41 d� f4 �/lp7' he 1 QH .4NCj 6. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18 C Commonwealth of Massachusetts �- Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address a�? Owner Owner's Name information is a(,�i �63� �i required for every 04 page. City/Town State Zip Code Date of Inspecti D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness --- Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: �I Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): l Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ,�nA Owner Owner's Name information is Ql A required for every page. City/Town State Zip Code Date of lnsActiorf D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date C"omments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Z--V`eP7 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.): M so/� f5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4`r Lam1 Property Address AlA �r Owner Owner's Name ) information i every required for every t A9 1906 35 � — page. City/Town State Zip Code Date of Ins ecti D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: 0a do, C4,,Y,, C-I&I'l- Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: ------- -- t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 i c� Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments co'4 Property Address a Owner Owner's Name information is co444— D 3S required for every page. City/Town State Zip Code Date of Ins6ectioit D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth-top of liquid to inlet invert layer Depth of solids la P Y Depth of scum layer Dimensions of cesspool - Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/26/2018 Title.5 Official Inspection Form:subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �. Subsurface Sewage �Disposal System Form -Not for Voluntary Assessments ' j A o;S it T Property Address Owner Owner's Name information is �t required for every Oo�63� 4 page. City/Town State Zip Code Date of In pectin D. System Information cont. Y (cont.) 13. Privy(locate on site plan): Materials of construction: - Dimensions - Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I 1.5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1s of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address A Owner Owner's Named`� / information is // required for every page. City/Town State Zip Code Date of I spe tion D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks o enchmarks. Locate all wells within 100 feet. Locate where public water supply enters the build' Check one of the boxes below: and-sketch in the area below ❑ drawing attached separately � !9y(laH sa�-rc 7n.. f d - So0 �-Ay- /]- d2- 6 y- t5insp.doc-rev.7/2 612 0 1 8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 �,I �. Commonwealth of Massachusetts 60 Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C ✓1 ST4ti Z—Al Property Address Owner Owner's Name C information isrequired for every page. City/Town State Zip Code Date of Inspec n D. System Information (cost.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar 1 ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ O served site (abutting property/observation hole within 150 feet of SAS) Checked with to I //Board of Health-explain, ,, ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must de a how you es ablished the high ground watery elevation: u ww�G 41 f C VV - d" Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doe-rev.728/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System orm -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Ins do E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: <AInspector Information: Complete all fields in this section. B. Certfcation: Signed& Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (F 'ure Criteria)and 6 (Checklist)completed D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Co o LTH of Mfg ii OFFICE OF&MWAL. ARS LE DLPPARTmzNT OF EEO .T'11 ,` +viAR , Lit LOT S 5 OMCUL INSPEMON FORM®NOT FOR VOLUNTARY SUBSURFACE AGE DEPOSAL STEM FORM PART A CERTIFICATION Proms Address: Owner's N=C MANy_ R �C��BYrS Ale- Date of �2( x Number: CFATEFICATION"STATFIdENT I CMMIY that I have pasomily inspected the swage dispoisal syst+:m at dus aft=ad dw ffie' below is Mr,accmm and Mete as of time tams of to" The kapecdan was pafirmed based on my in&t psopm Amcdm and suniumnamce®fom sate sawage fteeml rjsu=&I am a DEP approved sysam isspedor punmmt to Section 1 4 of This 3(310 CMR I ). Mm CondWanallyPams Needs Fudia Ewduamn by die LocalApproviag-Ambmuy l:aUls Inspector's Sigantmv-- Dzft:'Q� ZS— 'SWSUS a mff of dib kVmcd=reponto&a Appoviog Au&mity Qkmd ofHcd&or DEP)vft1ft 30 drys of If tam system is a Wbared symm or ho a dedp flow of 10,E Wd or .the hWPwW and the SYstem owner"submk the mport to of t� DEP.'Ibe adOW should be sm to the system owner and sent to to b%w,if a 9 Ie,and Notes and ***MbaePott ply d m at the bane of hopedion and under dw coudidm of we at the time.Tbb hapecdon don act address how the will pargarEm in th@ ftftm under tam ordiffarm �`. canditiow of am Page 2 of l 1 OFFICL41MAM+OPCF0 —NOT FOR VOLUNTARY ASSWNE4TS SUBSURFACI SEWAGE DISPO&AL SYSTEM INSnCTION FORM PART A . CERCATI®N(hued) AddMES• , i3wner: /. .yam Date of Saffimbry: Cheek AAC�D or E I S CD=Plde all of Semen D & System Passes. I lie'not found any lion whidt W'caWs bast any of flee fiA=caimia described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any faihav criteria not evaluated are ffidicated below. Casments: IL Syltm CondNewilly yes: One or more system C0111poneM as descrMed in the"Conditional Pese sew need to be n0koed or The swum,upon completion of the reply or rep*,as steed by the Board of Hea*will pass, Answu lam Yes,no or not detemdned(Y,N,ND)in the for the f0110wing .If"not determiner please The septic tank is metal and over 20 yars.o or the sep*tank(whdher metal or n&)is gruMway existing tank is mp�as mfiltratiOn Or �as Mmed by tank A&n� p� tim if the "A Board ofHeal& meta]sq*c tank will pass• if it is sound,not Waking and if a COMficate Of indicating that the tank is less than 20 years old is avail". Compliance ND explain: o Observmiw of sewage or 1 c a m or high static wow lavd in the�n box due to broken or p S)or due to a b okm,settled or nnam distributicm approval of Board of Haft). box System wffl passhupection if(yvnh brace pis)s i� bot is hVIDW orrephtced ND explain: ----- The system reqdW Pumping More than 4 times a year due to bran or OWM ted pipe(s)."�sy will iPass° if(w t approval of the Board of Hu th l brQkcn pis)are replaced obstnictim;sue ND aacpIWL. l Page 3 of l l ® CL4,L INSPEMO*6R� f e NOT FOR VOLUMARY ASSUSMMS SU SI ACE S AGE DISPOSAL SY D(S C' ON FORM PART A CE1k CAT10N( . Property►Address: ' Owner. Daft of o C- Further Evalmadon is Required by the Bwd of Been: Condition exist which vxp&e finiber evabution by the Board of HeaM m ader to detmm=e if the system is Hung to potect public heap,sefty or Ow GUMMMOIL 1. System wlil pass mless Ord of pith determines in amordanea with 310 15-3(1}(b)that the system is not bgcdologian womi, which will protect public beaWsafty sad the ronment: s` Cesspwl or privy is within 50 fiml of a surAws water r Cesspool or privy is withiim 50 fit of a or a salt mmsh 2.• Systems will fail unless the Board of Health(and PaNc Water Supplier,Ii any)determince that the system Is foactlonfmg he a manner that preteets the public health,sty and envirowamt The system has a septic tank and sod absorption system(SAS)and the SAS is within 100 feet of a space water supply or iributffy to a surface watm supply►. The system has a septic task and SAS and do SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and do SAS is wfdltin 50 he of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 fib but 50 fixg or more fmm a Private water supply well**.Method used "This system gasses if the well wateraubsis,puformed at a DEP czWled lebmsory,for col ifocm bacteria amd voladie osVmx empounds kdodes that the well is fine fiom pollutim from that fatty and *presemeofannoubilhimp, ad nkrade is egad to or lens tins 5 per,provided dW ao ether f4ute cry we A c M of tb a aaabWs=L t be attadnd to this f=. I I 3. Other. Page 4 of 11 O CLAL WSPEMON FORM--NOT FOR VOLUMARY -- SUBSU"ACE S WAM O SYSTM RMEMON FOB![ PARTA- ICAT' ON Address: fant,44 0 owner. do U Systent NWhn Crf#erla aNdte to all systems: you mast' 'or"ad'to each of tine following for&hopectiom Yes No A Bodap of seww isto facility or systwo componat doe to overloaded or clogged SAS or col _X Dbdwp orpouft of effluent to the surfte of the ground or sutfice waters clue to an ovaioaded or cragged SAS or cesspool Static ligtud level k the disrrMan but above outlet iavwt due to'an overloaded or clogged SAS or col ...._ .� Ikluid depth in cesspool is Im than C below hmwt or available vohnne is I=than%day flow ® Required pumping in=than 4 tip in the lass year WLdw to,clogged or obstructed pipets).Number of times Any poWm offt SAS,cewpool or privy is below high llnd water elevation. .__.. Any motion of cesspool or privy is within 100 feet of a surb=water supply or w'butary to a stnrtace water supply �. Any portion of a cal or privy is wig a Zone l of a pubho well. — Any portion of a cesspool or privy is widtin 50 feet of a private water supply well. Any pow of a cesspool or pr1W is less tw 100 Am big greater*an 30&a Horn a private water supply well web no acceptable.won quality p wthe wail water s, performed at a DIP cartiffed hilwatory,for coNhm bacterle and voletlle orp indicates ttrat the well b free few po0adon has tbat hefty mass the pry of ammonia oftnigen and nerraate z1bwn is a quat to or Iess tm Ina,prwMed that no outer Whim erlterIa are tr ered.A copy of the nmt be athiched to tbb t wm] P�SS (YwWd)The system A&I have deternifued that one or am of the above lhilare criteria eat as in 310 Chia 15-M,dwnhn dw system,DAL The system oww$Loin i ft Board of Fkd&to detumim what will be necessary to cm, &e fat'hum: L Lop Systesaw TobecumMendabWqstmacsystesompistsawa a wltlr: �w of 1 gpd tD YOU at 1W to Cich offt ('The Wowng Whim apply to Wp wftm in.adifton to the cawk above) yes no . ,,,,_ the systeni is wAin 4W fed of a surfim drinking wow mpply — — the systems is whin 20 Am of a U&uta ry hi a sarbo drUcing water supply —the is located in a nitrogen senshM area Onferiin Wellead Pwtecdon Ana—IWP.A)or a mapped Zone 11 of a public waste sue+well If7OU haw answered W hi any question in Seams E the system is Considered a tln fd,or answered "yes"in Sew D above the lama system Las biled.'she owner,or opw=of awi WV WOM congdgred a signifimant threat under Sew E or tailed under Section D sLell cede*0 system in mace wilt 310 C24R 15.304.Mw system owner should cowact the appropriate regional adllee of the DcpwMjc L I Page 5 of 11 OFFICIAL INSPiC nOXFOM-NOT FOR VOLUNTARY FORMASSESSMffM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PAR B CHECKLIST �Property Address: , Date of Inspection: Se Check ifthe fotlowi havebeendone.You most bftm"yes-or"sue"as to eachofthe folig!Ng: Yes No or Board ofHealth ! � Pumping information was provided by the owner,ocxt, Were my of the system componua pumped out in t&-previous two wceks? . _ Has the system received no%zW Rows in the previou two week period? .� Have jup vohmm ofwater been inigoduced to the system Moody Or as part of this° . ? Were as built plans of the and ?(If they w not available note as N/A) Was the&cft or dwelling JmspWW for ftW of sewage back up? Was the site inspected for signs of break out? Were all system components,mchtding the SAS,looted on site? _X Were the septic tank manholes uncovered,opt,and.the tnteri- of She tic inspected for the condition of the ba_ffies or tees, of off,dmeasions, of liquid, of scan? Was the facility owner(and occupazds if diffuml fium owner)FvvxW with information on the proper maboamme of subsurface sewage disposal System? 11w size and jocadog of the Soil Absorption (SAS)on the site ho beo deaummed,based on: Yes no For aunpK a pin at the Hoard of Ham. _ in the old(if say of the fiil=criteria re to Part C is at issue of distance . as le)[310 CMR 15302(3)(b) n IL I Page 6 of i l OFMCML INS MON ( gg - NOT FOR�fl7L�IyTMAy�R/I�'�A�FORM S�Si��,l!x S SUBSPACE,►7ae of AG :WS O1rSL S Sa71 SL'M 8i\�7PE S ON�'V DART C • -.SYSTEM EMRMATION Property A&b-.. Owner: `41le m Date of Imp '� 2S' O IWW COMMONS R MUM ro of bokwms( esi ). Number of bedroom(actwo DESIGN flow band on 310 G 15.203(far Pe: 110 ggd x#of ). •,910 Number of c _ Does residowe have a estop gander(yes br noy-&O Is kundry on a separaw sawage system(yes or no):.,.j°[¢yes separate on l LIUM&Y system hVwwd(yes or no). Seel use:(yes or no):. `�1 Ot f Wm >�, (1a�ta ( )• Boa �.- C P cD. 7, o , 3 - C P Isump Pump d Un or noX 0 ocovanw. .AT �zS 9 CONw=CLUJMUSTMAL Type of Design Boa►(based on 310 C R 15203): gpd Basis-of desip flow( etc_): Grove bw1 (vesu'no)-�. l vmft hokbg tam Fix q ent()es or no): N waste discharged to the Title 3 system(yes or no): Water mom ifavadsbk Lase data of mopmeyAme: - OTRER(desenbe): GENERAL INFORMATIOlq Soup OfilufmMlatiM Was system pumped as part of the' (yes or no):` IfM volume per: _Hoe,y s quantq P ? —Y,Sqm tak&Wflum fix,sot abswpdn system �. ffvw coWPool _ssystem(yes(a•no)(if M allach Fa vious• records,if any) InnovatiirelAkftwA"tockmology.Attad a copy-of thocUrrat Opondlon and maintenance wftw(to he obamed&=system owm) r..r �.Attach a aw of dtv DV �Otha( r Apprmdnuft age of all date iustalted(if lmom)and source of' 00, kv Page 7 of l l t3MC'IAL IrtsAC" 014 lb --NOT FOR Y®LIMARY AS3MMIUM SUBSUWACE SEWAGE DISPMAL SYSTEM]NSPFkMON FORM PART C SYSTEM INFORMATION( ) . Property Address: - 4 Daft of BUILDING SEWER(locate on site plan) Depth belol� lewerials of cm 1Hm X 40 PVC.o--otber(explain): Distance fi n private water apply well or suction line: Ccunem(on condition ofJohms,venm&woe of leakage,etc.): SEPTIC TAML (locate on sift plan) Depth below If t mA is nmd list age;:® h age confimed by a CArtificate of Conipliance(yes or no):®(attach a copy of ) IA022 -j1 Sludge :— Distaace fi=top of sludge to bottom of outlet tee or baffie: scum thick: L®A Dist=ct frmn top of sctnn to wp of outlet tee cr baffie: Dbtence f m bottoms of scorn to hougm of mdemtee or How wen diumnsions ga 67 = Comments(on; r 1dng t�ocxanmendations,inlet and outlet we-or baffle coon, l integrity,liquid lever as related to outlet invert, of lewaw, a G _..(ltce on site plan) f Matutwof constructim conmvm mwi polyethylene other Distance,from tap ofsm to top of outlet tee or baft Di0mcefivmboatmets, o is tee ov:bafllt: l?aftof lam • Cbmsemb- inlet and ot>tlet tee or baffle condition,jai' ,liquid levels as relates to outlet invert,eve of leakage,etc.): Page 8 of i l ()PPICLA-L JNSACn0l0FdkM-NOT FOR vLlI.MARY ASWMMMS SUBSMACE SMAGE DEPOSAL SYSTEM IlWECG'ON FORM PART C SY$rEM PMRMATION(continued) e Addrust 7 44-We Cm T i . Oancr: " . Dateof 2s TIGHT or HOLDING TAW- (tale most be pwnped at tin of" an site plan) Depdib*w.#a& Mal of contion:—Coacreft metal fibeeglass`_po otber(explai®� Dimensions: Design Flow. day Alarm-per(Vas or no): Alain krvet Ahum in working order(ya or no)• Date of last Cmmem(con0ion of wand Boat swaches,ete.� DIS'I'RI�U'TI BOM (if present mmt be opened)(locate an site ) DepYlt of limed level above outlet invert: Commcnb(note if box is level and li adon to outlets egnai,any evidence,of solids c oryover,any evidence of leakage into oropt of box, k P M CRAmWt; (locate on site plan) Paays in w (yes or no): Alamos in wading ardw(yeo Or W): C (note won of pwnp 4 ofpmops and am). Page 9 of l 1 OFFICIAL INSPZCnoN'FORM--NOT FOR VOLUNTARY ASSESS!' 4 TS SUBSURFACE SEWAGE DiSPOSAL SYSTEM INSPECTION FORM PART C 9YSTEM INFORIi+IA17ON(confl= ) .Property Address: c Q, i^✓d e Of &CA hqlactle n: oq SOIL ABSORMON SYSTEM(SAS).* (etc oo ate pwk nam0w tmt If SAS not laded explain WW. Type leaching pits,uunther. leaching galleries,number: leaching trewbes,numbff, leaching fields,munber, avaliow cesspool,number: system Typeftome oftr Comanents(ncft c m dmon of sod,signs of hy*anhc Mure,level of pow dank soil,condition of vegetation, etc.} S� 6,41-e-o )-/ I-e,4c Y C LIV>4fe YZ a/,.S 4,o Gg I eV Al-0 CESSPOOLS: (mil must be pumped as pact of i ron)(locm on site plan) Number and coaguration: tlepth—top of lid to ink invert Depth oflvjw Depth of scum layer: Dimensions of wool: Materials of "on: hHucathm of smum1water h1sow{yes or re); Comments(nqft cmdkion ofsoil,sips ofbydta dk h0aze,lei ofpondbi&condition of eme . POM: (lode on site per) of `ott • Depth af Co c7onditimt ofsot signs ofhydnmhc:fiftle,level ofpwal&cmiffition oftesewum etc.): I Page 10 of 11 SUMURFACE S AGZ DEPOSAL SYSITM INSPEMON FORM PART C < SYSTEM INFORMATION l PrOI'ty A�9$l'eS�o Ovum Deft Of SxwTCS ov.sEwAGE 38wwAL 9YSTEM Provide s dmtcb of the sewage dispasl system mcludmg ties to at kart two pamsmw rdormcc landmub or Locatic all wells wiffiiu 100 feet where public water supply eiia ia the bu0ding. i - I qq/ ,0. i '1 z / 1 I � / s a 6� �' J Page 11 of 11 OMCIAL IN CM®P•FORM—NOT FOR VOLUNTARY ASSESSNMNTS SIBSUWACE SEWAGE DISPOSAL SYSTEM INSPRMON FORM PAIt'I'C SYSTEM WORMATION(,cowbm4 PropertyAddrem- O�d Owner: Date of n: $ SrTZ EXAM Slope lsurtbice Walm. LCbWk callar. . Shallow weds Estimated depth to ground war 3 feet Please indicate(check)all maihods used to determnie die lit ground water elevation: f F 'Obamed from system Aga plans on turd-Mchecked,daft of design p1m reviewed: ObsmNed she(aWttingproperty+/ hole whbin ISO fed of SAS) amcked with local Board of Heald 4Mp(ain: L'hedced with local (ouch I ► ) Accessed USGS lain: _ You i3mile 40W you astah—li shed the A, �water el G�%�w.l' 11: �1 QAn o T aiei BOARD .OF HEALTH CITY/TOW N z - o , DEPARTMENT , 'o - ADDRESS TELEPHONE' ' Q h .Qt M +t AI Lp`{�#f Address --r- —� -- - Occupant . Floor 'Apartment No No.of Occupantsi No.of Habitable Rooms_Co No.Sleeping Rooms_? No..dwelling or rooming units _ No Stories Name and address of owner -. row lJ i Remarks Reg:. Vio. . YARD Out Bld s::. Fences.- Garbage and Rubbish Containers: Drainage _ Infestation Rats or other: STRUCTURE EXT. _ Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: i S 1 r' J r`c / 5bo Foundation: Chimney:. )e,,w d atv c cH /0 3b0 BASEMENT Gen.Sanitation: edrrav� ice, j J _wo Ikelk:J...I►� /O Dampness: N.- Stairs: 40kii Lighting: STRUCTURE INT. Hall,Stairway: . Obst'n. Hall, Floor,Wall,Ceiling: .. Hall Lighting: Hall Windows: HEATING Chimne s:_:(,vr d S 4upe dwat,, S f Ceritral ❑ Y ❑ N •E ui' .Re air TYPE: : ' Stacks, Flues Vents <:I# i.: A': ''3 � : ' . PLUMBING: up I Line: MS ❑ ST ❑ P Waste Line: N S: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.:Z oaf +S o-" (i/a// ►v, N �e>INo k6(.Qq1P 7l/ ❑ 110 ❑ 220 Fusing,Grnd::. AMP: Gen.'Cond.:Distrib:Box; .,. x A:• Gen:.Basement Wirin DWELLING UNIT. . Ventil. , L to . Outlets Walls Ceils. 'Wind. Doors; floors; Locks DOI s 'Echen. :: QK- athroom s+ Z Pantry Den Living Room Bedroom 1 1-1edroom 2 P,edroom 3 Bedroom 4 Hot Water Facil. Sup:Ten.;:Gas, Oil, Elect.: Stacks,r Flues,.Vents;.Safeties: Kitchen Facilities Sink; Stove Balzin Toilet Facil. . : �:Vent:;Plumb.;Sanit'n.::;. - Z 9� 6 �l�3 w rQy, Wash-Basin,Shower,,or•Tub. Infestation Rats;Mice, Roaches:or:Other. Egress Dual and Obst n 1:• General : Buildin Posted. :Lock§oh Doors: I,, I .: ONE OR MORE OFITHEVIOLATIONS CHECKED ABOVE IS A CONDITfON,WHICH' MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL BEING1*OF THE . . i OCCUPANT AS DETERMINED.$Y•105CMR 410:750'OF THE;; COD�,OR THE AUTHORIZED INSPECTOR (So b Over) i}f k v¢+ fti `THIS:INSPECTION REPO T IS S.I ED AND CERTIFIEDiUNDEIR THE PAINS.AND PENALTI F.PERJ INSPECTO DATE J I Z.f P� ;I ', r . A• TIME_ �D. �� P.M.,. THE NEXT SCHEDULED REINSPECTION O ti A. l r Town of Byrn �2ble Departm, ent Qt Health, 54-teti, and Environmental Ser/icas . Y.A a Public Health Division -4Er N12in StrEet, H"Yannis NIA 02Ea1 FAN Da[e: _f 6 Nt rnce:Gfcazts [a taitow 3 Ta//:ll r rO/m:: /^j V� I JC V 1 ail /I In V�'� T7 a V✓ l'�'lS t � f y. J r thane: 4 z C Phcne: ;03-363'6 r Fes: oherie: M-790-6304 CC: �ec0r,LmC,[ qG Ley . ... .. .. Stable Z 2 0°3 498 929 i �----4 �� = u`�llll r rn_ re s �x� 5138443 « I `4 JEAN MARIE & WAYNE SANBORN s 99 BATHERICK ROAD 01473 ap, �� "7 GMT (. o 1 • �� � � lst NOTICEVIA ro- a 2nd Nr,T IC — `� RETURiVcD i SECTIONCOMPLETE THIS ON DELIVERY SENDER: COMPLETE b A. Received Please Print Clearly) B. Date of Delivery _ 7- ■ Complete items 1,2,and 3.Also complete y( item 4 if Restricted Delivery is desired. ' ■ Print your name and address on the reverse C. Signature so that we can return the card to you. ❑Agent - ■ Attach this card to the back of the mailpiece, X ❑Addressee . or on the front if space permits. s D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No iGel U , 3. Service Type ``JAG p 101 Certified Mail ❑ Express Mail P x I c y y ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O:D. -..�. 4. Restricted Delivery?(Extra Fee) ❑Yes 2• py from service label) j 1 f PS Form 3811,July 1999 Domestic Return Receipt 102595-99-M-1789 i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,,MASSACHUSETTS Zippfication for Digozaf *pgtem Cow6tructiou Vermit Application for a Permit to Construct( )Repair( XUpgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. !�7 y Owner's Name,Address and Tel.No. sO,�N Assessor's Map/Parcel Installer's am ,Add s,and Tel.No. Designer's Name,Address and Tel.No. 1-4- 54AL Type of Building: Dwelling No.of Bedrooms a Lot Size sq.ft. Garbage Grinder(A6 Other Type of Building tr No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 'U_0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) a E'er .• ct!� Date last inspected: Agreement: The undersigned agrees to ensure the construction and mainten ce of the afore described on-site sewage disposal system in accordance with the provis' ;ir�onwpnt de and not to place the system in operation until a Certifi- cate of Compliance has en issued by t ' f Sign Date j —/ 7 �� Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issixed o. V� 3� / - �4 Z12 N ee 7THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01ppYication for Migpool *pgtem Congtruc 'on Vermit Application for a Permit to Construct( )Repair( ,Upgrade( )Abandon( ) ,RfComplete System 1:1 Individual Components i Location Address or Lot No. ro0j§4,1Owner's Name,Address and Tel.No. Cam" ` U , ��yNe SAiv bdrN Assessor's Map/Parcel Installer's Na/m�,Addre s,and T-1.No. Designer's Name,Address and Tel.No. �l0rtlfCJC 0O K1T/t1_ Type of Building: 1 Dwelling No.of Bedrooms CA— A Lot Size sq. ft. Garbage Grinder( �J Other Type of Building _ A No.!of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ZA o gallons per day. Calculated daily flow o gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,y d.09 r� Date last inspected: Agreement: ' 1 The undersigned`agrees to ensure the construction and maintenatice of the afore described on-site sewage disposal system in accordance with the provisions-of-Title-5_ f iron enta de and not to place the system in operation until a Certifi- cate of Compliance has b en issued by th' o f he t Sign _ �i` 4 Date 7-®d Application Approved by v �` Date Application Disapproved for the following reasons Permit No. Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS "} BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( �)Repaired ( )Upgraded( ) Abandoned( )by tt �� r Ur :7. C at o w has been constructed in accordance with the provisions Jof'Title 5 and the for^Disposal System Construction Permit N dated Installer H�is N �`0 Ic 4 ,r� , Designer S9,0,f 4 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Ins ector_ No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 'Wigpogar bpgtem Congtruction Vermit QPermission is hereby granted to Construct( )Re air(V)Upgrade bapd op )��w System located at / 7 r6,u4 ,1 U �Ai and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction : usust/be completed within three years of the date oft per-mit. Date: ( �// l�� Approved by i / r ✓ V , 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) r I, wig-r"00 r5 hereby certify that the application for disposal works construction permit signed by me dated 3! —/ 7— Oc , concerning the property located at / 7 rwus%Ai� AJ meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation .40 +the MAX.High G.W. Adjustment. _ DIFFERENCE BETWEEN A andVIA44-� SIGDATE: [Sketch proposed plan of system on back]. q:health folder:cert - TOWN OF BARNSTABLE :G. LOCATION IT !- L aeW-4 - SEWAGE # ?&c-,-- 7 3 ' `MLAGE (—/2+1 2 t ASSESSOR'S MAP & LOT G 06 INSTALLER'S NAME&PHONE NO. 4h 4 CIN11i, O 4 SEPTIC TANK CAPACITY 91 1 LEACHING FACILITY: (type) �i�!u le�� '^2(size) ® d NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: >3 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility_(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by lam' ID i TOWN OF BARNSTABLE , G LOCATION C C-0. SEWAGE # 7 VILLAGE /ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. , y f SEPTIC TANK CAPACITY ,IdOl� g/ LEACHING FACILITY: (type) ,Di`L/ (size) �S✓�% ' �'t NO. OF BEDROOMS BUILDER OR OWNER L ,P PERMITDATE: —( Y -®e) COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility.(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i i 7-7 j l:rf�t F • I Vy" k - 0` � ten..+:+' � 1..: :� •I .� FORM30 Hw HOBBSBWARRENTM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �(4 s-Wok- CITY/TOWN DEPARTM NT + A WIGS S+_ �-�- ADDRESS � /_ TELEPHONE Address/___<-� 6­ �1 4-44 1-9- W�14 _ Occupant Floor Apartment No.— No. of Occup nts No. of Habitable Rooms (v No.Sleeping Room No. dwelling or rooming units— No.Stories Name and address of owner- arjt . Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: $ j , Foundation: Chimney: BASEMENT Gen.Sanitation: r� 1ut zw (; G, Dampness: -ei mil) -✓(/O Stairs: 4, 0643 Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: / Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ftudytpfS r$26L4,xj Jo Y, ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation- Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIG IED AND CERTIFIED UNDER THE PAINS AND PENALTI ERJ Y.' — INSPECT / TITLE G v� M. DATE h l v TIME l�= A.M. THE NEXT SCHEDULED REINSPECTION P.M. , �. k- � 'sae*-r=.q'f.+s.� �">"�r <�'i. f llti'k°'^�1,�, F�,....,. .Y P� t *� F t�t. � �!' yh a S ,I" ;S• ii�M _h wr� �i :;.,fir '.eyr'e.X ziir. ++�4..a �#"'"�{`k" �M';�'; 1tt"" � ;'� 4hiti a�rSM,�^,°�7`vN4•:i�'•�*'�",eei. .^�'YG.�".'Jk;�'}'N•,,�1!�:+7�i}'.,t,'' dC;�,# 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements'of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) ,Failure to provide a•toilet and maintain a'sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G)' Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105'CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through.199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or . other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as.to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. Town of Barnstable Regulatory Services °� rO Thomas F. Geiler, Director BAMSTABM Public Health-Division "cb `0� Thomas McKean, Director ATFD N10�A 367 Main Street, Hyannis, MA 02601 Office: 508-862.-4644 Fax: 508-790-6304 September 11, 2000 Jean Marie& Wayne F. Sanborn 99 Batherick Road Westminster, MA 01473 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE H, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE, ARTICLE 51 The property owned by you located at 17 Constant Lane, Cotuit, was inspected on August 31, 2000 by Glen Harrington, R.S. Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code H, Minimum Standards of Fitness for Human Habitation were observed: 410.280: No window was provided for the basement bedroom. 410.280: The master bathroom vent was observed to operate improperly. Vent must exhaust to outside air. 410.351: Two outlets on west wall in master bedroom were observed to be inoperable. 410.500: Siding was observed to be missing on rear of dwelling. 410.500: Water damage was observed around chimney in garage. You are directed to correct the violation of 410.351 (outlets) within twenty-four(24) hours of receipt of this notice. You are also directed to correct the remaining above listed violations within thirty (30) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. EFR RDER OF THE BOARD OF HEALTH oFas . McKean Director of Public Health sanbom/wp/q/1s l i �pF THE Tp� * BARNSTABLE. # Town of Barnstable 9�A0390. `0� TFo�.A Board of Health 367 Main Street,Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Ralph A.Murphy,M.D. Brian R.Grady,R.S. 2000 ��-1c�c , ,�of NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00,STATE SANITARY CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 1.7 L0 ,was inspected on 12000 by Glen Harrington,R.S.Health Inspector for the Town of Barnstable,because of a complaint. The following violations of 105 CMR 410.00,State Sanitary Code II,Minimum Standards of Fitness for Human Habitation were observed: 0 s c is1('G q 10. 2 ?'® /(/o (,✓ 116"Ar 4 (-.to-3 4 i" ale + ,. lT�+�rmcL►� v Z ci A�laj b9 Vcv-•( dloSew-i—ed Ju P)aL'c,,k 'e�rS I� Sv��^-� L�ea.�z1). !/ems-f- �.J� � ` 10. 3�1 I wn o u4(,P-+J o L— i,,,_e 3 C�6if �6 W& l/wiS C -.S o v ve.a., llW�.fj ({ l 0 moo Qv a ate, rn�a v L 6ev vt d G v c.�,.cJP e l �� 6- q10, 'Sf I (0,41e+) You are directed to correct this violation of 4 within twenty-four(24) hours of receipt of this notice. .. You are also directed to correct the remaining above listed violations within seven(7)days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven(7)days after the date order is received. However,these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than$500. Each separate day's failure to comply with an order shall constitute a separate violation. Renting the above property with uncorrected violations is a violation of the State Sanitary Code and the Town of Barnstable Rental Ordinance,Article 51,section 6-2. PER ORDER OF THE BOARD OF HEALTH Thomas A.McKean Director of Public Health I Enclosure: Copy of Inspection Report I t Health Complaints 30-Aug-00 Time: 9:20:00 AM Date: 8/30100 Complaint Number: 2519 Referred To: GLEN HARRINGTON Taken By: GLEN HARRINGTON Complaint Type: CHAPTER II HOUSING Article X Detail: Business Name: Number: 17 Street: CONSTANT LANE Village: COTUIT Assessors Map-Parcel: 6 ,p Complaint Description: SHE WAS UPSET THAT HER LANDLORD KNEW ABOUT FAILED CESSPOOL THAT WAS CAUSING ODORS IN HER BASEMENT AND IT TOOK HIM A YEAR TO FIX IT. THE INSTALLER SAID THAT IT WAS NEVER PUMPED IN 19 YEARS. SHE SAID THAT HER KIDS SLEEP IN THE BASEMENT IN A ROOM WITH NO WINDOW. A WOOD STOVE IS THE PRIMARY HEAT FOR THE BASEMENT(PERMITTED). Actions Taken/Results: HOUSING INSPECTION SET FOR 10 AM, 8/31/2000. Investigation Date: Investigation Time: 1 i 1=xn,+�Map P�r�e 039067 nd OWr�er Farce I 039067 e1 © V cou t . ' 000234 a t 0000000 f` Y 11AC euel Hof LOT 43 o Sipe 74 ' err Oven SA MORN,WAYNE F& tate C las 101 � 99 BATHERICK RD /_ d e �x 00 .;, r y �WESTMINSTER a 00 0 i � � MA 01473 ��we ac a�y 000 000 D d 000000 � � � Reference�, C8 0 e 23 nary, ,s1 SANBORN,WAYNE F& ;peedMMYY 0000 fee„ efi. C84203 � es ' 000034900 Bid I i gam: 000068500 r Fea 'e; 0000000000 LeoIciri 17 CONSTANT LANE aad lr�tlx 0347 Frn 0187 6i�p►st' CT �_� � � ' � / '�_ / HOPEWELL LANE c d$x 0739 ,rr�tg 0267 �� � s FORM30 ��w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN w o DEPARTMENT ADDRESS // yy TELEPHONE Address �5 �-K L�' � f Occupant /tq6L(4,C/ & Floor Apartment No. No. of Occupants A No.of Habitable Rooms No.Sleeping Rooms Ze No.dwelling or rooming unit No.Stories I Name and address of owner 4- fp,13Q h Remarks Reg. Vio. YARD Out Bld s.: Fences.- Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: .LIB ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: "4(ZJ bj im v�GGa✓. /p 15bp Foundation: Chimney: (A o. o wI�+e cti /v SYl® BASEMENT Gen.Sanitation: yr h s ,} ---v'otv",.dfo>U i;v P Dampness: Lin Stairs: Li htin k STRUCTURE INT. Hall,Stairway: i Obst'n..- Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING C h i m n e y s: S S .3 Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: d"_ Ir ❑ MS ❑ ST ❑ P Waste Line: A14A_,# H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.:Z o v o-" 6y. (4/&(/ tJ, In ae I hff c�6(.� O 3TI ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond..Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks 0124- Kitchen Bathroom 311_� Z Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: e&" p(e✓1 tvYevr Wash Basin,Shower or Tub.- Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPO T IS SI ED AND CERTIFIED UNDER THE PAINS AND PENALTIESF PERJ Y ,A INSPECTO TITLE �//4A M A. DATE 0 �P TIME ODd/3-77 P.M. THE NEXT SCHEDULED REINSPECTION w �-"�1� !� Ur A M C�.�...(Xr�P.M. r � r� i�dkr �py,. ;7 4�C'�Yr��'r`��•*R�! � rW1�.r31 t � xAl�. r 7iNliN�'�,ii+ �`{�k%�1'Y; 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. L Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, O P 9, 9 9 9 P P 9. 9, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant"or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or.furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system'which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. Z� 2 3- 502 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for InternsAonal Mail See rev rse n o t um Mice, e, I ode Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee LO Return Receipt Showing to Whom&Date Delivered a Retum Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ th Postmark or Date LL I (L f �r Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service Z window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q) return address of the article,date,detach,and retain the receipt,and mail the article. 3. If u yo want a t a return receipt,write the certified mail number and your name and address � on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article n RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the 611 addressee,endorse RESTRICTED DELIVERY on the front of the article. 00 t M j 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. L`oL i 6. Save this receipt and present it if you make an inquiry. 102595-99-M-0079 a Town of Barnstable Regulatory Services °FTHE l° Thomas F. Geiler, Director Public Health Division + BARNSTABlz • � Thomas McKean, Director A'�D110�a 367 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790 6304 September 11, 2000 Jean Marie &Wayne F. Sanborn 99 Batherick Road Westminster, MA 01473 NOTI_CE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE H, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE, ARTICLE 51 The property owned by you located at 17 Constant Lane, Cotuit, was inspected on August 31, 2000 by Glen Harrington, R.S. Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code H, Minimum Standards of Fitness for Human Habitation were observed: 410.280: No window was provided for the basement bedroom. 410.280: The master bathroom vent was observed to operate improperly. Vent must exhaust to outside air. 410.351: Two outlets on west wall in master bedroom were observed to e ino perable. operable. 410.506: Siding was observed to be missing on rear of dwelling. 410.500: Water damage was observed around chimney in garage. You are directed to correct the violation of 410.351 (outlets) within twenty-four(24) hours of receipt of this notice. You are also directed to correct the remaining above listed violations within thirty (30) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a.hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. RDER OF THE BOARD OF HEALTH �omas . McKean Director of Public Health sanbom/wp/q/]s COMPLETE • ON DELIVERY ■ Complete items 1,2,and 3.Also complete A'Received by(Please Print Clearly) B. Date of Delivery item 4 if Restricted Delivery is desired. (_,(;1`;' -�\ � ■ Print your name and address on the reverse so that we can return the card to you. C..Signature ■ Attach this card to the back of the mailpiece, c rENAgent or on the front if space permits. X '6 j,�tr v��`(i ❑Addressee D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No 3. Service Type &Certified Mail ❑Express Mail A ❑Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. O 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number(Copy from service label) PS Form 3811,July 1999 Domestic Return Receipt 102595-99-M-rrB9 y �,AER E UNITED STATES POSTAL SERVI �� a, i4 OCT • Sender: Please print your name, address,and ZIP+4'in t is box • n TOW of&llmlu s PA Box 534 i joyann1%Massathusetts 02601 ''•""' .. �-• - �'�' ill!!lfl�.l�l��f3.i�llflfs�l�lf f !i jjjj }} j j } }} lfl� P�oFTHE, � Town of Barnstable Department of Health, Safety, and Environmental Services BARNSfABLE, MASS.1639• Public Health Division ♦0 A'EON`0�� P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health RECORD OF VERBAL COMMUNICATION O„'K/ •v"t L V S V-e3'veJ 6*Yjy rl GQS— c.-M2 y/v. c7b SGZiw� G r S� r rA;-1 a44 A4,,I VA A S 4- S a�, cu t vej .So d d�.d�s D h �� � n o` �k - -u 7'�e_ a/ae sue/ S 41. Gt AA t do 6-4 cam, � �� �- � w� � �-,u.�,d� ate-S �. y-� ,-,�•►-� , verbcomm.doc e � . N ..fzo...............s Fes$....:....�................ THE COMMONWEALTH OF MASSACHU SETTS BOARD OF HEALTH A.a._..................OF.......... ............................... Apptiration for Uhgp ial Works Towit ur#ion "emit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. C .................................... ..........-•--- Owner Address a � I----- nsta=-ller------------------•----------------------- ----------- Address....•--------------------------------------- PQ Q ype of'Buildin/ _ Size Lot..3� "�.__...•....-•---Sq. feet V Dwelling No. of Bedrooms:__..._._ .. Expansion Attic ( ) Garbage Grinder ( ) �-+ ------- - `� Other—T e of Building No. of persons__________________---------- Showers — Cafeteria Other fiixtuures ................................ W Design Flow.............�7 ........................gallons per person per day. Total daily flow-----:�--C,.___. _ ..._gallons. ---------- WSeptic Tank—Liquid capacity_1OM.gallons Length................ Width•-.___-____-___- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width................. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.---____I............ Diameter....f 0.......... Depth below inlet.............. Total leaching area 19......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) $0 Percolation Test Results Performed by. .�'�`L I{?..��tQ 1►.:�4!"4...._ ... Date..�..... '_�'�...-�.............. ,aa Test Pit No. 1.....2.......mmutes per inch Depth of Test Pit-----i.11-------.. Depth to ground water____ _ _____ (i Test Pit No. 2....... ......minutes per inch Depth of Test Pit......!._ -...... Depth to ground water.... •------- -t.:......---••-----......-•-••••-•- '--- - .................................•......................................................... ODescription of Soil.......6- -- ; ------------------------------------------------------------------------------------- W ................ VNature of Repairs or Alterations—Answer when applicable.-_-._.......................................................................................... --------------------------------------------------------•--------•--•--------------------------•-•-•••--••••-•••-----•--.......-•--••••-•--••••••--•------•---------•-•---••••••-•-•••-•---•----•...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i T`:�,^ p of the State Sa ry Code—The undersigned further agrees not to place the system in been is ued by t board of health. operation untila Certificate oCompliance ned -b-••- -•--- - -- •-- .. •�`�_:'.----•----•--...... ..�.�.^.................. Application Approved B �:- -' . . . ...................... ..... D � r�PP PP y------ . Date Application Disapproved for the following reasons:................................................................................................................ ---•................••-------------------•--•------...-------•---•-----•------------------------........._ -Date PermitNo......................................................... Issued....................................................... Date - 1 .. F I3 FEs:- .............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. ; . OF........... .!1.R.n!. .fl:a`�c. .................................. Appliration for Bi-spoaul Works Tomiuurtion rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ' ) an Individual 'Sewage Disposal S stem at L OLl 5"Sf4!� ........�....'�.----•�.. "��?--------------------- .................................................... ..------...... . ..... Location-Address or Lot No. Owner Address W ` 41D- --•--------•-----------•------•----•---•--------•--•--- Installer Address vt ?v7 pe of Build Size Lot-- .---..___Sq. feet V r Dwelling No. of Bedrooms---- _ -__--Expansio Attic ( ) Garbage Grinder ) aOther—Type of Building ............................ No. of persons..../..................... Showers ( ) — Cafeteria ( , dOther fixtures -------------------------------•------------------------------ lysW Design Flow............................................gallons per person per day. Total daily flow............................................ 310 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.....0......... Total leaching area..... .....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) l ? r aPercolation Test Results Performed by._W...M:%3 _ .!...'!...� ..e--•------------------ Date.....................___----- Test Pit No. 1...... _____minutes per inch Depth of Test Pit------. ► Depth to ground water----- 0l� ___........._ Gz, Test Pit No. 2.....t'Z._......minutes per inch Depth of Test Pit----------��____-_-- Depth to ground water...NAA(-. D Description of Soil � r °�a �.-- f1 M1 $,j v1� �, l ---•- W ----••--------- ------------••---•••-•••---••...--•••--••-------------------------------•-••------------•--•-•••----------------•--••-•--••----------•••••--•-••---•--------••--•--•-•••-•--•••----••--- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..__-•-•--•••••••••--••--••........................•••-•••••••••-••-•••--•-••-•-••••••••----••-•••••----••-••_...._..•-------•--•----••------•-•••---••-•••---•--•--•••-••••••-•---•--•......-------•-•- Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'T L p '5 of the State San' a y Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance a een is ued by t board of hellth. /Sned _ _�. ._. ... Application Approved By......... � - Y' �--�! _._ ....................... / Z.... ---- Date Application Disapproved for the following reasons:..................................................................................-............................. s -•--•------------•-••-••-•-•-•---•••--•••-••-••••-••••-•-•-•-......-----•.......••-•-•----•-•••--•._.......••••••••....••••••..............••----••-•----•••-...••....•-•-_.........-----•............--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... d Z.; OF ...................... J Tnxtifiratr of ToutpHaurr �S TO C/ IF at the Individual Sewage Disposal System constructed ( 0r RepairedbyPIS ��t'`fj'"' `•-G _._.. .. " Installer at 6i ---0 ' +`��---.--•--- .CJ--LJ.f%-----!--✓-- -----•---<.!efw....-- ......... ..................................................... has been installed in accordance with the provisions of TT >.of The State Sanitary Code as described in the SU application for Disposal Works Construction Permit No. _..G ....�.................... ..._......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................. --� ,� Inspector r —._w.•:a35C �-CA, "S`µ =3L+•N�''vl!'«1�3'' t+r `.fa"k'i"*�„ R.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .� 7S s..::...................................OF........-- ~�� .................................... - N FEE.. l �i��o I�I�or�$ o , tra�rti�n .erntit Permission is hereby granted �' '•-------------------"-"-------------------------------......-••--•......-•-•---••_.. Y g ����� to Construct ( or Re air ( an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit No. 's ...... Dated__.____--------------------•--••......--- �r --------•- h ............................... (7 Board of lYealt DATE... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS a Yu Fri 1per ,n tr.p ko 0 L IA' �}� S 's 2 2- 5 6 Z o O o 0 c) di:- r P, t >T�t t Co-ru i-T- ,; 0C h WALr'R Al , ,r w .r �,4 r N OCj '' S�A$�e p �• R�^•� !�a1 h� �l'f1- Ito 7z D44- 48,0 47 7' aca (,p r. D1ANt. _ a64 Cor-lG• t�AGN�tJGt I O oo C-cal. Caac. ,, b 6 Da j r Se P r Ta M k- '415 4 0 eAA4 ��r ► .1 / 40,5 A bdb -� 2 µraiArd s+ono BOT P,T E.,..Ev /44 48 �O D CIRQUNo o „ 5 �Sa 1 E 5 i C-_N D A,-rA zo TEST RF'aRMED APRii- . Z 3, 1980 Mrdium 3 C-3e.apoomc, x Ito GPI? - 330CIi { LEACHIQ'Ll Kecll Itj O C-iAPZE3A4G L ` Po_ _ $E I Oo D SAL_ Jt- C o0ase Ct,,PAf IT I j'K ���J l t1 lr U J. o T-r�tu� T5 Z x i O = 78 5`7i r T ( Coin Si vt~ sTlo x T CJ a, r- ti A F C : T�i FtZo v 1 G 'eC �5 -`r ,7, L J�,�c_nt^z o�•r��� v�r r T+-� v , , o N S F o P T F4 E r oc . r I J i Coy-u,4 Gd>u>t�of N 6 rU o n c� W o r- r Q n 5�4 eE T _ N 0 � P 3 � s \ a s, 3 v t M s wo H �' t 38 h d s Io k E 2 CAR