Loading...
HomeMy WebLinkAbout0197 RALYN ROAD - Health �0-t(At 197RALYN . cl i II � FORM30 C&W HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS t BOARDF HEA TH CITY OW DEPARTIfiFNT ADDRESS GSM SvOy`oW G TELEPHONE Address `�`�'�(` _ Occupant_. Floor Apartment No. No.of Occupant No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units_ No ries Name and address of owner Q o Remarks Reg. Vio. YARD Out BI s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: it ` ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: LW Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: 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.: ❑ 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 5 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: ,Aqqks, Flues,Vents,Safeties: Kitchen Facilities Sin ve _ 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 INSPECTIO REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENAL UFiY." INSPECTOR TITLE DATE TIME P — ' A.M. THE NEXT SCHEDULED REINSPECTION P.M. r 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of 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 bf 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 Ieadbased 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. 14 00 YOU WISH TO OPEN A BUSINESS? �' j��v For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, V FL.,367 Main Street, Hyannis, MA 02601 (Town Hall) ;I DATE: S Z 6 b Fill in please: _ APPLICANT'S YOUR N rC2 ZOFS k (2 BUSINESS HOME ADDRESS: q7 R �✓ -M TELEPHONE NAME OFsNEWBUSINESSLaJAB , ELYMER412i5CS TYPE OF BUSINESS. 'JAo e 'c IS THIS A HOME OCCUPATION? YES NO Have you been given approval from the building-division? YES,,—No ADDRESS OF BUSINESS A2 MAP/PARCEL:NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. . corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual.has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual has been ' rmed of t e e_rmit requirements that pertain to this type of business. Authorized Signature* COMMENTS:��D lZ �Y1�7�evtct-�i Zvi STf� 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature**. COMMENTS: x Date: S /,;;76 / ®( TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 9HAEa k Pkis S BUSINESS LOCATION: IT7 tFALY1V 12 COI_U17-1 i 3S INVENTORY MAILING ADDRESS: )q�7 12AL& 12d TOTAL AMOUNT: TELEPHONE NUMBER: 41' '472'yy72 CONTACT PERSON: (206EL�?Zo�SK y EMERGENCY CONTACT TELEPHONE NUMBER: 617 ���Z "�� MSDS ON SITE? TYPE OF BUSINESS: �,�1�►aie,SaL ,Z' INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111 , Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) _ Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor & furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers �n hLL2. Mom- (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS .•. /26/01 DATE, -3 PROPERTY ADORE SS:_ Cotuit,Mass. 02635 -------------- on the above data, I Inspected the aeptlo •OMOf� at the aboye address. This system conslsts of the (ol.lowing 1 . 1 -1-000 gallon septic tank. 2. 1 -1000 gallon precast leaching pit: Based on my Inapecllon, I certify the following cohdltlona: 3. This is a-title five septic system.. ( . 7k Code ) � 4:- 'The s p is system is in proper working order Q B 'G _at., the._Present_-time. 5. Pumped the septic tank at time of inspection. Heavy scum & solids layers were present. 6 . Leaching pit was dry at time of inspection. S I G N AT U R E: ./ Company; b Son , Inc . RECEIVED N - Address .- Box---_ 66-----_- _ ----__--_ IFIA Z00.1 +_Centerva Ile L N8 ,-02632-0066 TO H ELTHDEPT BLE T. Phone ; THIS ceA7IFICAT10N.'00ES NOT CONSTITVTe A OVARANTY OR WARRANTY JOSEPH P, MaCOMBER & $ ON, 1NC, Tinki•C�iipooli•l,�ac"'# ds Pumptd 4, Initsll0d .- Town s#.wor .Connsotlons Box 66 C•nlrrYlll4, MAl 02632.0066 775 JJJB 775.641Z COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 199 Ralyn Road Cnt'I]it- FtaSS_ Owner's Name: Geralri P1 ai Gnhman Owner's Address: _7_P2.a_,_TXave1ers Tree_ Rnr-arat•nnrPlnrirla 1 4433 Date of Inspection: 3 /?r /n 1 Name of Inspector: (please print)Joseph P.Macomber Jr. Company Name: J.P.Macomber & Son Inc. Mailing Address: Box 66 Centerville,Mass. 02632 Telephone Number: 508-77 5--i 338 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 rrainine and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: jeV Passes' --—Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: < ' Date: -- `� i The system inspector shall Zit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system.or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments e ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I f ' Pape 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 197 Ralyn Road Cotuit,Mass. Owner: _Gerald Fleischman Date of Inspection: 3/2 6/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.r =s;teimPasses: _2 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: T-Pa! r-h i ng i t- wa c rl ry a t t i mes of i n Gppc-t i on B. System Conditionally Passes: IP 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: } A)dxltr Observation of sewage backup or break out or highjuadLw=r level in the istribution box ue to broken or s� obstructed pipe(s)or due to a broken, settled or uneve distribution bo . 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: Al,?)_ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will - pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:1 97 Ralyn Road Cotuit,Mass. Owner: Gerald Fleischman Date of Inspection: 3/2 6/01 C. Further Evaluation is Required by the Board of Health: VP 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: ADD Cesspool or privy is within 50 feet of a surface water ,f2d 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: yO 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. /UO The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. y6 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 thann 100/��!feet but 50 feet or more from a private water suppl%:well". Method used to determine distance /�U �1J/9/ey` "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 r Page 4 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 197 Ralyn Road Cotuit,Mass_ Owner: Gerald d 1 pi schman _ Date of Inspection: 3 f F /01_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N�Discharge _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 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, e Ooy 7 _r_1/__ Liquid depth iri4oeapeo is less-than 6'"below invert or available volume is less than 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped J—. ZAny portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a.surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Z 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.) A/D (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15,303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400-feet of a surface drinking water supply tithe system is'within 200 feet of a tributary to a surface drinking water supply i the system is.located in a nitrogen sensitive area(Interim Wellhead.Protection Area— IWPA)or a mapped Zone 11 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 "eves" 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 r Page 5 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 197 Ralyn Road Cotuit,Mass. Owner:Gerald Fleischman Date of Inspection: 3/2 6/01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No umping 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 ? . 1L — 041 _ Were all system components' omponent luding 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. —Z_ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 I� Page 6 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 197 Ralyn Road Cotuit,Mass. ` Owner: Gerald Fleischman Date of Inspection: 3/2 6/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .1— Number of bedrooms (actual): �' e DESIGN now based on 310 CMR 15.203 (for example: 1 10 gpd x k of bedrooms): �Xl �T Number of current residents: _ ) Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no): (if yes separate inspection required) Laundry system inspected ges or no): Seasonal use: (yes or no): / Water meter readings, if available(last 2 years usage (gpd)): f �� �/v �� '��,v,�� ���f' A Sump Pump(yes or no): ��• DdD —I" ,el le � Last date of occupancy: 1: 2zAxW' ; COMMERCIAL/WDUSTRIAL Type of establishment: Design now(based on 310 CMR 15.203): _� gpd Bast; of design flow(seats/persons/sgfi,etc.): Grease trap present (yes or no): �[�} Indusrrtal waste holding tank present (yes or no): Non-sanitar-y waste discharged to the.Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): q/ GENERAL INFORMATION Pumping Records Source of information: 1��9s'/00M"r" ';-XVX — V Was system pumped as pan of the inspection (yes or no): . yes, volume pumped.J�Q gallorys How wasqn�q PpmPe� determined? � y /�PS� Reason for pumping: d TOF SYSTEM 7Septic tank, ' soil absorption system VQSingle cesspool _ X1 Overflow cesspool Privy &Shared system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Altemative technology. Attach a copy of the cur-rent operation and maintenance contract (to be obtained f7om system owner) N�6Tight tank &Attach a copy of the DEP approval /Other(describe): Appr .rimate age of all comDorients, ate ins Ile (if kno )and sourc of informati n: Were sewage odors detected when arriving at the site (yes or no): 6 s Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1 97 Ralyn Road ` Cotuit,Mass. Owner: Gerald Fleischman Date of Inspection: 3/2 6/01 BUILDING SEWER (locate onsite plan) Depth below grade: _ Materials of construction: cast iron A PVC 41,lother(explain): --e,14 Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear t.ight.No evidence of leakage.The system is vented through the house vent. SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete metal 4�d_fiberglass&opolyethylene &)other(explain) If tan}, is metal list age: is age confirmed by a Certificate of Compliance(yes or no):A'�(anach a copy of certificate) t , Dimensions: 7 '� x 1 ! /� 1 Sludee depth: Distance from to of sl dge to bonom of outlet tee or baffle: Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bongqn of outlet tee or baffle: How were dimensions determined: �,�T�¢�" „i� Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump the septic tank every 2-3 years. I'nlet & outlet tees are" in place-The tank i G' Gtriir f-iiral-_S11Und and shows nn evidence of leakage. GREASE TRAP4&?,(locate on site plan) Depth below grade:A214 Material of construction:,/4coricrete�metal.d�fiberglass;lkpolyethylenei&other (explain): i1J14 Dimensions: .64 Scum thickness: L11? — Distance from top of scum to top of outlet tee or baffle: AA40 Distance from bonom of scum to bonom of outlet tee or baffle: _ Date of last pumping: 4140_ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not prPsent, 7 f Page 8 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 197 Ralyn Road Cotuit,Mass. Owner: _Gerald Fleischman Date of Inspection: 3/2 6/01 TIGHT or HOLDING TAN1C0�V'p- (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: 41A Material of construction: 4)4 concrete v4 metal ,)A fiberglass �1.� polyethylene 414 other(explain): Dimensions: AM Capacity: AIA gallons Design Flow: 44 gallons/day Alarm present(yes or no): Alarm level: (/$ Alarm in working order(yes or no): Date of last pumping: ,f74 Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not present DISTRIBUTION BOXA&a (if present must be opened)(locate on site plan). Depth of liquid level above outlet invert: 4).4_ 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.): Distribution box is not present PUMP CHAMBERtvn.C(locate on site plan.) Pumps in working order(yes or no): Alarms in working order(yes or no): 4 Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump chamber is not present. - y 8 Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 197 Ralyn Road Cotuit,Mass. Owner:Gerald Fleischmsn Date of Ins lction: , 3 26 01 180 0 �r� SOIL ABSORPTION SYSTEM (SAS): JZ(locate on site plan,excavation not required) If SAS not located explain why: Type Zleaching pits, number:'L _A2_a leaching chambers, number: leaching galleries,number:_O_ leaching trenches,number, length: 4 _Z2&leaching fields, number, dimensions: a overflow cesspool,number: D 7— G innovative/alternative system Type/name of technology: %V Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy sand to sand.No signs of hydraulic failure or nonding_ Soils are dry.Vegetation is normal. Pit c; ind r th - asphalt- - with cast iron ring & cover to grade. CESSPOOL&/CYO(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1� Depth-top of liquid to inlet invert: ,{ Depth of solids layer: /Q Depth of scum laver: ,tJiq Dimensions of cesspool: A14 Materials of construction: Indication of groundwater inflow(yes or no): AA- Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): ('-PG�i nnl c arp `nni- present PRIVU)a (locate on site plan) Materials of construction: Dimensions: Depth of solids: AW - Comments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Privy is not present. 9 l _ Page 10 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 197 Ralyn Road Cotuit,Mass. Owner: Gerald Fleischman Date of Inspection:3/2 6/01 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. s x . Cleo" 00`;� ' 3' dtT '.. 'T�t�tl"1' c COd—rzf i i0„ o i' 10 I 016A o0 LO AT ION SEWAGE PERMIT NO. VILLAGE INST- AA LLER'S NAME i ADDRESS BUILDER 0 OWNER DATE PERMIT ISSUED J 3 _ DATE COMPLIANCE ISSUED f - .. - --- ----- -._ ..-- ....... - Page I 1 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propem Address: 197 Ralyn Road C_ otuit,Mass. Owner: Gerald Fleischman Date ofinspection:326/01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground waterAb feet Please indicate (check)all methods used to determine the high groundwater elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: 3' l E��cked Fwit bunin g=Ralth-explain: observation hole within ISO feet of AS) ca oa rQ , bu)'2,,-, y3,/ Checked with local excavators, installers- (attach documentation) — Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used Water Contours Map Gahret-y R Miller Modpi 1 1 6/Aa 11 v P � •t'"'••-n.•r•Ir-•ram- Tf�.-mr'nmrnrrrrt reR..rrl�r•.7r++TrlTnf+�m+fts*•tL 1...'.RTI.IRT .T1r9-rr lr-�.-- '- T 'I'UWN OF Barnstable WARD OF HEALTH SUIISUNFACF SEWA(,F DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION 1 ....->•.••r..•..r-r..r.•.-*-n.r.rr..•nrn TTm'rtarr*r�'.'—•.•,-,urn-�a..n.r�-.w.....r ns+.m..�r. nrmn�rsr-.trr.rn•..—.rrrr-.-. .-. 1 -TYPE OR PRINT CLEARL1'- PlIOPERTY INSPECTED STREET ADDRESS 197 Ralyn Road Cotuit,Mass. ASSESSORS MAP , BLOCK AND PARCEL # 022-056 OWNER' s NAME Gerald Fletschman PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inarw. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 1 790 - 1578 CERTIFICATION STATEMENT - I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of -inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal. systems . Check one : System; PASSED The inspection which I have conducted has not found any information which indicates •that the system fails to adequately protect public health or Lhe. environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have conducted has found that the system fails to Protect the E)ublic _health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . 7 Inspector Signature �,4wzv, Date 'e O( wne copy of this certification must be provided to the OWNER, the BUYER here applicable ) and the 130ARD OF HEAL'I'1I. * It the in FAILED, the owner or"*o pgrade ' tho vyetem within one y orator shall u Pear of the date of the inspection , unless allowed or required otherwise as provided in 310 CHR 16 . 306 . partd . doc LO AT ION SEWAGE PERFAIT NO. VILLAGE Co-ty INST�►A�LLER'S NAME i ADDRESS S UILDER 0 OWNER DATE PERMIT . ISSUED DATE COMPLIANCE ISSUED o"**' `27, tPO c OOrr`e - o moo, -- J No.......... s_........ F>�s... ................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town........................OF........8arnstable Applira,tion for Uiipniial Workii Tomitrurtinn amit Application is hereby made for'a Pe mit o Construct ( X) or Repair ( ) an Individual Sewage Disposal System Lot #18 - ---..................... ......•------------....•........... ....-- ---.. .----••---........--•----------•------------ Location dd ess j (/ RaYlY not ..........7------------ - . .-•----------............-•••--•--- O ... wne r Address a i --t u i t Mass. --.----•----------------•----- ---•----------------------------------------------- Ins ler Address � Type of Building Size Lot----1fa_,_5.0.0........Sq. feet Dwelling No. of Bedrooms............... L-U .......................Expansion Attic (n c) Garbage Grinder (no) Other—Type of Building ............................ No. of persons...f O U r ----- --- Showers ( ) — Cafeteria ( ) Otherfixtures ......n o n.e---------------------•--------------I.............................................----------•------------------------•--••-•------ W Design Flow...............5._............_......_.__gallons per person per day. Total daily flow.............2.2Q.......................gallons. WSeptic Tank—Liquid capacity...NiaQallons Length................ Width,............... Diameter---------!'......Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching apea....................sq. ft. Seepage Pit No.--__----_-_______- Diameter.6 !x S '-- Depth below inlet+.. ............... Total leac 'ng area..................sq. ft. z Other Distribution box ( X) rD�smg tank ( ) .0; J d-t`�, PE '-' Percolation Test Results Performed a_fl.d...Tay l.Q_lz.................... Date..... 1--3 0_-?9.........__.. as Test Pit No. 1.....A minutes per inch Depth of Test Pit ................. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ ........----••---...-•...............••-•-••-• •... • . ... x Description of Soil...... = - ?+� c -{ - .... .._ r w -•---•••--------------------•------•------------------•••----------•••--•---..._....--•-......-••-•--------•-•----------------------•--•---••-•-•-•-•-•-•-•••••---•--••••......------•-•----•-••----•- UNature of Repairs or Alterations—Answer when applicable.......:...................................................:................................... •--------------------------•-------•---••------------------•-------------------------•-•---------...-•-••--•-•----------------------------------------•-----------------------•••...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITILL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 's e by th�oflli igned. •......• .......... ---------------------------- Application Approved BY , = ........... �`- D�....------•... Date Application Disapproved for the following reasons_________________________________ ___________ ••......_.___ •--------------------•----•--•-------•--•-•-•----------•------------•------•------•--.......---------••-----•--•-•-•-••••---•--•-•••---------................................. PermitNo--------------------------------------------------------- Issued.. �•`�_7- r i -..� THE COMMONWEALTH OF MASSACHUSETTS • _fir;. _ - '.:r BOARD OF HEALTH r T i.on .....................OF...-...Barnstable ..--.---------•--•-------------------------------•- i t r ,�l r rlir�t a an for Dhipoii al Morkii Cron.5trnrtion "[rrmi# A lication:i Y s'hereby made a P Disposal nit o Construct X or Repair an Individual Sewage PP ,•s ��,•, ( ) P ( ) g System, F C. ....... .1... • .......................•-•. ..____•_•______._._________•_••___••. __. ______-_•-______-___-_____________-______ • '4 Location Address �ovr Lot�No. wn Ioad l�a� Address ....... W 1_ t * iCX rl7::=: ....... ...........................................• t ._ _..... _..: _ _ In tiller Address c d Type of Building ;. Size Lot...1.6. . " 0.__.....Sq. feet Dwelling • rNo. of Bedrooms tuit7______________________Expansion Attic (no) Garbage Grinder (1n) � -,:,:-Expansion 9) !P-------------- ________________ No. ersons._... _ Showers — Cafeteria p., Other , Type of Building _____... p ( ) ( ) 0therfixtures, ._none-----------•-••-•••-•.•-----•--•----••'--------•--------------•-••-•••........----•-• ............................................ W Design Flow S5 F; .................gallons per person per day. Total daily flow__._......._220.___.__.._..____........gallons. 04 `Septic Tank—rLiquid capaezty__� gallons Length ______________ Width,...:.._._._.__. Diameter---------------- Depth................ t Disposal Trench No Width �._._._.... Total Length Total leaching area__________________sq:ft. '• e z� Seepage Pit No....�_ Diameter�.'..x.. _+___ Depth below inlet__'..... ......... Total leaching area...........-......sq. ft. Other Distribution box Dosing,tank r t '-' Percolation Test Results Performed by. we�..I.1___l�n d_.a.Y 1`?�' ................. Date..... �-30 7 ..____...r_. aTest Pit 0 1 � minutes per inch Depth ofd'Test Pit . Depth to ground water.................. fitr M ,. Test Pit I o:2._.__: ` minutes per inch Depth of Test'Pit......................Depth to ground water..____...... ....._..: P' ./ O Description of oll .._... l .................... CL' � ��, � # ... ... L.�¢�l s --•- W -. Nature of Repairs or Alterations—Answers when applicable ...._________...°:................ .._..........:__.._..............___. . a: .. Agreement `' ' The undersigned agrees to install lthe aforedescribed Individual Sewage Disposal System in accordance with r' the provisions of i 5"of the Statd Sanitary Code—The under,'signed further agrees not to place the system,in .k operation unt>la Certificate of Compliance has been is's ed by the board f heal n '- r X' { .. f Igned D Application ApprovedBYs : ` •••• " r e - ,....0 2 Date Application Disapproved:f oza the following reasons-------------------------------------------------- ------------------------------------------------••------- a..:. . k e F - Date Permit:No..._..- .__. Issued....................................................... x� Date THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH OtiUti Barnstable V' ' ..........................:.............sOF...................................................................... .-. : r afiratr of flonapli�ant/r THIS IS TO CER FYIhat�Y o vidual e z e Disposal System constructed (X or Repaired ( ) by ; .! ...-� L.r,ILL � � R 1yn Road, Cotuit , i4 ss. - at-----_----- - -----••------- ------------------------F­ THE = --------•---------------------------------------•------•------•••--------------- has been costa ied in accordance with tile provisions of Tj of The State Sanitary Code as de-cri d in the application for,bisposal ��Vorks Construction Permit No.. j ._:`............... dated__..-_ .,�?-..> ..-_..._..__.._._..... ISSUANCE OF 4THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL' FUNCTION SAT SFACTORY s h DATE.. �yL 'Z Inspector •----••--•---•---•--•-•-- a " Y pu:.nu•.+,.„q x•t iwv''9t }F„gr :. -,. '•;Y �xi h � �f Yi•�., '"� �., � ,.�' .',� :,x� r c a� � - THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH c Town Barnstable .........OF.................................. No............. = FEE...-•-••................ Daopoottl_ orko n ' n Permission his hereby granted.-•----------=-------- ------ '� �� to Construct ( ) or Repair ( ) an Individual Sewage Disposal System !.©t'at No....... .....1.. 1 y1Y..{?...: d.:. Cotu t.:..._ a ---------------------------- ............................................................... a Street application for Disposal ���orks.Construction Penn No______ _______ Dated._ " '" - --_--- as shown on the �s .. A'410 d-D Board of Health DATE-----------=- ...........c '__ V FORM 1255• HOBBS & WARREN, INC.. PUBLISHERS . 4 4\ /40 a /. 12N> A-1 i t %�C' ` S j3 a/��/nfG s ETL3AC� �c-ct'�u/e�ME�irs SC.4 ,ao 5ED 5E P T/G :�y5 TEM CONS T2 UG T/ON B���pMS SHA `-L c_pNF02M TO MASS . ,(DES/G�l/ FLOfN �=- �=-t� GAL./ En/✓/eOA//yZN7_,4L. I—OnE. T/TLC Y L7L1 Y r-! ?_'/- 7 7 ";-. />r"+✓.n., jy r L LAC/W 2.4 7E L` L- �•///V.�/ , TOrU OF A EAL77A-1 T�`C-,CJL,47-/ONS �Equ/,eGo �EacN , 2Z,� u,%/C>,�?71 2?.O 2 OF PE,4 STrJ/v� MANNoLc �E To � F/N/S h TE n!v 7-0 /'t'/pE,t2✓/OUS o✓E / OJ/ 7-A4/n/ / TC� .a2G VeA.17- E5 / OF H�� �2AD� G• S �20 T2.4 7/n/(3 �J _ `� � I� '� �..--� coves 2°o••G.P..�� - v +sT/_zo �. -_- ; 30X i Z/ "w.De Ov"e 3"MAN —6" v — Pr r M/n//ry✓it/ _ .R. —— 'r _ ._3 Mr v 4.,D/A MIA7 , F.Z- Ft Oc✓ .:r vE M/,V _ T- _V_ • , /O L,2.Q "10i, C" � I 4; FO p /o"MiN i ii P T Mn �r r�fr / ,,./ �.. D/a. T VGAL Dni S 7-0 n/E /N✓EeT ' CA pA C / Ty /N✓E A-_7' 1 ?-� L 7 4L �•E�T/G TA N E /'�+� J ELEV• , A2Oun/O / (IIVA 7 A2 Ttv/ 7) 8d7TOM Of= ---J =—� /NVE2T "�C /N V E A,2r _.-- 20 /v1/n./r nit UA1 S / TE pL A A/ rro ,c748{ � L-L7vA / /c/v •- � ��(a cxc$4� 4 I 4 CDT TAN,<r l7/_> T2/3UT BOY Ah/DrO LEL1GrW/�/C`a F'�T COn/c'2Z rE S r,LG.V 5r�V 0000 psi D .14 T ` _. n �,� �: �. pe U Tak/ �"� n�1,�4. 5 ..�.a a✓� s u/v� - 2 T/�Y THE P�oPo s�D Fou��dAT/� ✓ w ,,',,�'�E-S A,I L C-),4 C>/,vim /S cois',,PFc7' ogs .5,vow,�v .9_*WV .O v4C S T,ME" �Er%�...�.�.�%c'�- ,• „t} __•.�._y - -- - ..._____._____.____. _..._ # 'ac T Mom' SVJ. 1R. 1 ,5'.E 7- .dA C i1' Ec 1.977. of SUR - 1 r