HomeMy WebLinkAbout0150 SCHOOL STREET - Health 150 school.Street
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Cotuit-
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William E. Robinson PARCEL.
Septic Service :GT
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT
OF ENVIRONMENTAL PROTECTION(revised 6/15/2000)
TITLE 5
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 150 School Street RECEIVED
Cotuit
Owner's Name: Catherine Hayden
Owner's Address: 160 Pine Street#20 APR 2 7 2004
Newton,MA 02466
Date of Inspection: March 8, 2004 TOWN OF BARNSTABLE
HEALTH DEPT.
Name of Inspector: (Please Print) David D. Coughanowr,R.S.
Company Name: William Robinson Septic Service
Mailing Address: P.O. Box 1089
Centerville,MA 12632
Telephone Number: (508)775-8776
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
training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP
approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system:
X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature ��-S "�� Cfi �0 �-
p g Date.
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority
NOTES AND COMMENTS
Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger
any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed
on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 150 School Street
Cotuit
Owner: Bradford Stephens
Date of Inspection: March 8, 2004
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: ,
A] System Passes:
Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR
5.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below.
COMMENTS:
B] System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no,or not determined(Y,N,or ND). in the_for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not),is structurally
unsound,exhibits substantial infiltration or exfiltration, or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout or high static water level in the distribution box is due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with
approval of Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced.
ND explain
The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will
pass.inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain
2
Page 3 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 150 School Street
Cotuit
Owner: Bradford Stephens
Date of Inspection: March 8, 2004
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety and environment.
1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2) System will fail unless the Board of Health(and public water supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety,and environment
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a,
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has 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 by a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form
3)OTHER
3
Page 4 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 150 School Street
Cotuit
Owner: Bradford Stephens
Date of Inspection: March 8,2004
D) System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.
The basis for this determination is identified below. The Board of Health should be contacted to determine what
will be necessary to correct the failure.
yes no
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high groundwater elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X 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 by a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form)
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore, the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E)Large 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
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 t
Zone II of a public water supply well.
If you have answered"yes" to any question in Section E the system is considered a significant threat,or answered
"yes" in section D above the large system has failed.The owner or operator of any large system considered a
significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 150 School Street
Cotuit
Owner: Bradford Stephens
Date of Inspection: March 8, 2004
Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following:
Yes No
Y _ Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the last two weeks?
Y _ Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of this inspection?
Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A)
Y _ Was the facility or dwelling inspected for signs of sewage back-up?
Y _ Was the site inspected for signs of breakout?
including
Y _ Were all system components,exelud the SAS. located on site?
Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for
the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of
scum.?
Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper
maintenance of subsurface disposal systems?
For information on the proper maintenance of subsurface disposal systems'please go to:
WWW.ECO-TECH.US
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Y _ Existing information. For example,Plan at the Board of Health.
Y _ 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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 150 School Street
Cotuit
Owner: Bradford Stephens
Date of Inspection: March 8, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file.at Health Dept.
Number of current residents 2
Does the residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection.required)
Laundry system inspected (yes or no): n/a
Seasonal use(yes or no): no
Water meter readings,if available(last two year's usage(gpd): 50 gpd
Sump Pump(yes or no): no
Last date of occupancy: Current
' r
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow(based on 310 CMR 15.203):: gpd `
Basis of design flow(seats/persons/sgft/etc.):
Grease trap present: (yes or no)_
Industrial waste holding tank present: (yes or no):
Non-sanitary waste discharged to the Title 5 system: (yes or no).
Water meter readings,if available:
Last date of occupancy/use:_
OTHER: (Describe):
GENERAL INFORMATION
PUMPING RECORDS
Source of information: System not pumped in recent past(Owner)
Was system pumped as part of the inspection: (yes or no) No
If yes,volume pumped: gallons--How was quantity pumped determined? `
Reason for pumping:
TYPE OF SYSTEM:
X 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/Alternate technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner) t
Tight Tank Attach a copy of the DEP approval
Other(describe)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Age: 12+years Certificate of Compliance issued 12/23/91 (BOH permit#91-569)
Were sewage odors detected when arriving at the site: (yes or no) no
6
Page 7 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 School Street
Cotuit
Owner: Bradford Stephens
Date of Inspection: March 8 2004
BUILDING SEWER_(Locate on site plan)
Depth below grade: 1.5 ft
Material of construction: X cast iron _40 PVC other(explain)
Distance from private water supply well or suction line 20+
Comments: (on condition of joints,venting, evidence of leakage,etc.)
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling_
SEPTIC TANK:Yes (locate on site plan) .
Depth below grade: 10 inches
Material of construction: X concrete metal_fiberglass_polyethylene
_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth: 6 in
Distance from top of sludge to bottom of outlet tee or baffle: 28 in
Scum thickness: 2 in
Distance from top of scum to top of outlet tee or baffle: 9 in
Distance from bottom of scum to bottom of outlet tee or baffle: 13 in
How dimensions were determined: Probe to top of tank
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Pumping recommended within 1 year and maintenance pumping is recommended every 2 years. Liquid level at
outlet invert. Tank and tees appear structurally sound and functioning as intended.No evidence of leakage in or out.
GREASE TRAP: none (locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments: (on pumping recommendations;inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 School Street
Cotuit
Owner: Bradford Stephens
Date of Inspection: March 8, 2004
TIGHT LD R HO
LDING O ING TANK: none (Tank must be pumped at time of mspection)(locate on site plan).
Depth below grade:
Material of construction:_concrete_metal fiberglass polyethylene—other(explain)
Dimensions:
Capacity: gallons
Design flow:_gallons/day
Alarm present(yes or no):_
Alarm level:_ Alarm in working order(yes or no):_
Date of last pumping:
Comments:(condition of inlet tee, condition of alarm and float switches etc.)
DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: at outlet invert
Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.)
D-box appears structurally sound with no evidence of leakage in or out.Effluent level at outlet invert
Few solids in tank.
PUMP CHAMBER: none (locate on site plan) U
Pumps in working order: (yes or no)
Alarms in working order: (yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 School Street
Cotuit
Owner: Bradford Stephens
Date of Inspection: March 8,2004
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required)
If SAS not located, explain why:
Type:
X leaching pits,number 1
_leaching chambers,number
_leaching galleries,number
_leaching trenches,number,length
_leaching fields,number,dimensions
_overflow cesspool,number
—innovative/alternate system Type/name of Technology
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.)
Soils above leaching pit appeared unsaturated.No evidence of surface ponding breakout, lush vegetation or
other evidence of hydraulic failure was observed. Leach nit contained 24 inches of effluent in a 6 foot pit
CESSPOOLS: none (cesspool must be pumped at time of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
PRIVY: none
o e (locate on site plan)
Materials of construction:
Dimensions:_
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
f
Page 10 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 School Street
Cotuit
Owner: Bradford Stephens
Date of Inspection: March 8, 2004
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'(Locate where public water supply enters the building)
LOCATIONS
A B
1 24 It 19 ft
2 29.5 f t 23 It
3 37 It 27 It
4 44 It 40.5 It
5 64 It 43 It
A
WATER LINE
EXISTING
DWELLING
ITIC
ANK LEACH
O PIT
#150a
6
SCHOOL STREET NOT TO SCALE
10
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 School Street
Cotuit
Owner: Bradford Stephens
Date of Inspection: March 8, 2004
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater: 35+ feet
Please indicate(check)all methods used to determine high ground water elevation:
Obtained from system design plans on record-If checked. date of design plan reviewed
Observed Site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of health-explain:
_ Checked local excavators,installers-attach documentation)
X Accessed USGS database
You must describe how you established the high ground water elevation.
Barnstable GIS department records indicate that property is over 35 feet above groundwater table
11
Catharine Hayden
1.60 Pine-St: _#20
Newton, M A. 02166
June 26, 1996 5
Ms. Christine Kuchinsky
Town of Barnstable Health Dept a
367 Main St.
Hyannis, MA. 02601 ^
Dear Ms. Kuchinsky,
Thank you for your recent inspection of my rental cottage at 150 School St., Cotuit.
which we discussed in my phone calls to you on June 25 and 26:
As I understand it, even though I had'asked the Health Dept. and my contractor if I had
to install a screen door, (and was told I didn't), in fact the house does need a screen
door to accompany the newly installed second door. Also there are a few loose floor.
tiles to be attended to inside.
As to the outside light,,. this light is not required by code. If it can be repaired`
reasonably then I may leave it. Otherwise, I will direct my electrician to remove it.
I am trying to find another carpenter because unfortunately, Tim Grey is not available
and is contracted out for a whole year (..literally until March or.April1997). When the
work is completed, I will notify you.
Sincerely,
atharine Hay on
- :Owner F
The Town of Barnstable
":,IN,T Department of Health, Safety and Environmental Services
MARK
oM�Y�.e`� Public Health Division
367 Main Street,Hyannis,MA 02601
Office 508-790-6265 Thomas A.McKean
FAX 508-775-3344 Director of Public Health
June 25, 1996
Katherine Hayden
160 Pine Street, Unit #20
Newton, MA 02159
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 BOARD OF HEALTH'S NUISANCE
CONTROL REGULATION NUMBER ONE
The property owned by you located at 150 School Street, Cotuit was inspected on June
18, 1995 by Christina Kuchinski, RS.Health Inspector for the Town of Barnstable,
because of a complaint. The following violations of the Nuisance Control Regulation
Number One Regulation and the Sanitary Code H were observed:
410.500: Several floor tiles in the livingroom were not secured to
the floor.
410.500: One floor tile in the master bedroom was not secured to the
floor.
410.552: The sun room door that opens to the outside was not provided
with a screen.
410.351: The outside post light had broken glass, exposed wires and
was not secured to ground (post had fallen into the bushes).
You are directed to correct the 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, this violation must
be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. Each separate days failure to comply with an order shall constitute a separate
violation.
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are corrected.
PER ORDER OF BOARD OF HEALTH
°Thomas A.McKean
Director of Public Health
cc:Marian Newton
Mr./Mrs. � _
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410,00, STATE SANITARY
CODE II, MINIMUM STANDARDS OF FITNESS FOR llUMAN HABITATION
AND 'TILE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51
The property owned byyou located at / � ( � a
"� -�Co6 inspected on
by C 4G,W f health Agent for the Town of Barnstable because of a
complaint. 'i'he following violations of the Town of Barnstable Rental Ordinance
Article 51 and the Sanitary Code 11 were observed:
YAe
/U, 5-6o D,,
Kt 4- die .
VA)
p
r«
u are i ected t orr t the atio f ours ' t�of this
You are Mw directed to correct the ramoining 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
I ealth within seven (7) clays aRer 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 (lay's failure to comply with an order shall constitute a separate
violation.
You are also subject to non criminal citations of$40.00 for the first violation and V 5.00
for each additional violation. Tickets will be issued daily until the violations are corrected.
Enclosed are citation numbers due to violations
observed on
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
Town of Barnstable
FORM 36HOBss&WARREN,WC.NOV.1979-1983 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
rz.r-j,,-j-/,6 j,6Ir(
a CITY/TOWN
o r ( DEPARTMENT/
a s,yy ADDRESS
TELEPHONE ,� y
Address Occupants-1 r h
Floor Apartment No: No.of Occupants
No.of Habitable Rooms No.Sleeping Rooms
No.dwelling or rooming units No.Stories d
Name
�and address ofowner // .n
!ea o P f tv {' l/11, -A, �D, A) ' �C)1 �V emarks 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: hr,-m1,. 4-o C, 6 UA f'YaIA
Roof V Sl� laCais
Gutters,Drains:
Walls:
Foundation:
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 E ui . Repair
TYPE: Stacks,Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels,Meters,Cir.: PO-4 J;-h4 . t9A- W I k e f
❑ 110 ❑220 Fusing,Grnd.: 6 C! �Gs(
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring '/e ,r-
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry9
Den
Living Room X
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 Facll. 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 SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY..."
it,�� /��/'G�f� 1C �-Ifs _
INSPECTOR �►� TITLE .�P-/' +-
// A.M.
DATE_ /I/I�' / ! L TIMEM•
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises,
shall be deemed conditions which may endanger or impair the health, or safety
and well-being of a person or persons occupying the premises. This listing
is composed of these items which are deemed to always have the potential to
endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499
state minimum requirements of fitness for human habitation, any violation has
the potential to fall within this category in any given situation but may not
do so in every case and therefore cannot be included in this listing. Failure
to include shall in no way be construed as.a determination that other
violations may not be found to fall within this category. Nor shall failure
to include affect the duty of the local health official to order repair or
correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833
nor shall it affect the legal obligation of the person to whom the order is
issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity; pressure
and temperature, both hot and cold, to -meet the ordinary needs of the occupant
in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or
longer.
i
(B) . Failure to provide heat as required by 105 GLAIR 410.201 or improper
venting or use of a space heater or water heater as prohibited by 105 CMR
. 410.200(B) and 410.202.
(C) Shut-off and/or failure to restore electricity or gas.
(D) Failure to supply the electrical facilities required by 105 CMR 410.250(B),
410.251(A), 410.253(A), 410.253(B) and the lighting in common area required
by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage system in operable
condition as required by 105 CMR 410.150(A)(1) and 410.300.
(GI Failure to provide adequate exits, or the obstruction of any exit,
passageway or common area caused by an object, including garbage or trash,
which prevents egress in case of an emergency 105 CMR 410.450 and 410.451.
(H) Failure to comply with the security requirements of 105 CMR 4110.480(D).
(I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602
which results in any accumulation of garbage, rubbish, filth or other causes
of sickness which may provide a food source or harborage for rodents, insects
or other pests or otherwise contribute to accidents or to the creation or
spread of disease.
(J) The presence of lead-based paint on a dwelling or dwelling unit in
violation of the Massachusetts Department of Public Health Regualtions for
Lead Poisoning Prevention and Control 105 CMR 460.000.
(R) Roof, foundation, or other structural defects that may expose the
occupant or anyone else to fire, burns, shock, accident or other dangers or
impairment to health -or dafety.
(L) Failure to install electrical, plumbing, heating and gas-burning
facilities in accordance with accepted .plumbing, heating, gas-fitting and
electrical wiring 'standards or failure to maintain such facilities as
are required by 105 CMR 410.351 and 410.352 so as to expose the occupant
or anyone else to fire, burns, shock, accident or other danger or impairment
to health or safety.
(M) Any of the following conditions which remain uncorrected for a period
of five or more days following- the notice to or knowledge of the owner
of said condition or conditions: _
(1) lack of a kitchen sink of sufficient size and capacity for
washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either operable.
(2) failure to provide a washbasin and a shower or bathtub as required
in 105 CMR-410.150(A)(2) and 410.150(A)(3) and any defect which
renders them inoperable.
(3) any defect in the electrical, plumbing,- or heating system which makes
such system or any part thereof in violation of generally accepted
plumbing heating,• gas-fitting, or electrical wiring standards
that do not create an immediate hazard.
( )_ failure to maintain a safe handrail or .protective railing for every
stairway, porch balcony, roof or similar place as required by
105 CMR 410.503(A) and 410.503(B).
(5) failure to eliminate rodents, cockroaches, insect infestations and
other pests as required-by 105 CMR 410.550.
(N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A)
through (M) shall be deemed to be a condition which'may endanger or materially
impair the health or safety and well-being of an occupant upon the failure of
the owner to remedy said condition within the time so ordered by the board
of health.
75: (2 )
ROBERT L. JOHNSON
Building Inspection Services
459 Boxberry Hill Road
East Falmouth, MA 02536
508.564.4006
June.` 10, , 1996
Marian Newton .'Re-Structural Inspection at :
P.O. Box 1944 150 School Street
Cotuit , MA 02635 Cotuit, MA
Dear Mrs. Newton,
The following is a report of` the inspection you have requested
to be done at the above address.
The results of this inspector ' s observations are on the
original building frame only.
1 . The dimensions of the floor joist are only 2"-0 x 4"-0
and are spaced at 24"-0 on center as compared to 16"-0 on center; .
which is the normal spacing. In one area the joist were spliced
together with no supporting girder below for support.
2 . The 4"-0 x 6"-0 girders . that support the floor joist are
14 ' -0 in length. The ends of the girders (at certain locations)
have been notched down over the foundaton walls which weakens
the girders. There are notches also at mid span of the girders. ,
3. The span of the girders ' is too great at several, locat'ion.s
between walls and existing column supports. This causes sagging
and weakness in the floors. Also, there may not be the necessary
cement footings under the floor that can carry the weight of the
building frame above. .
4. There are obvious sags in the (roof ) ridge .line.
5. Sagging is also visible in the upper section of the rear roof .
6. The building ' s front wall is out of ',plumb as much- as 111 . +
(The location is at the left corner board. )
7. There is rotting wood, prior insect damage, cracks and holes
in the framing members and obvious carpentry work of poor quality in
the first, floor framing system.
Based on the aforementioned defects and shortcomings of the
building ' s framing system, it is the opinion of this inspector that
the section of the building: that has the full" ,basement below the first
floor, is not structurally sound and that a structural engineer should
be contacted concerning this matter.
Very truly yours , ;
RLJ/cav Certified Building Inspector • Buildin Code Consul t
ai SENDER: I also wish to receive the
;o ■Complete items 1 and/or 2 for additional services.
y ■Complete items 3,4a,and 4b. following services(for an
d ■Print your name and address on the reverse of this form so that we can return this extra fee
card to you. 4;
°Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address
permit.
d ■Write'Return Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery
■The Return Receipt will show to whom the article was delivered and the date S'l
delivered. Consult postmaster for fee.
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UNITED STATES POSTAL SERVICE First-Class MailPostage&Fees Paid
USPS
R Permit No.G-10
• Print your name, address, and ZIP Code in this box•
Health Deportment
Taal,®t Barnstable
P.O. Box 534
Hyannis, ftsaftegtts 02601
Fax(503)775-3344
Peons(508)790-6265'� ,
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�OfTHE The Town of Barnstable
i DisalrAu Department of Health, Safety and Environmental Services
"6 9 ,� Public Health Division
�0 MAY�' .
367 Main Street,Hyannis,MA 02601
Office 508-790-6265 Thomas A.McKean
FAX 508-775-3344 ;_'Director of Public Health
M
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June 4, 1996 ;
Katherine Hayden `
160 Pine Street#20
Newton MA 02159 k
Dear Ms. Hayden: f
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On May 7, 1996 a re-inspection of the property owned by you located at150 School
Street, Cotuit, was conducted by Health Inspector, Jerome Dunning. At that time all of
the violations were in compliance.
Sincerely yours, t
!
omas A. McKean ti ~
Director of Public Health
Town of Barnstable
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February 29, 1996
1
M.S. Katherine Hayden
160 Pine Street No. 20
Newton, MA
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 150 School Street, Cotuit was inspected on
February 23, 1996 by Jerome Dunning, Health Inspector for the Town of Barnstable
because of a complaint. The following violations of the Town of Barnstable Rental
Ordinance Article 51 and the Sanitary Code H were observed:
410.481: The owners name, address, and telephone number was not posted near the
main entrance of the building.
410.482: No Smoke detector provided.
410.450: No second means of egress provided.
You are directed to correct the violation of 410.482 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, this violation
must be corrected regardless of any request for a hearing.
.. 1.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. Each separate day's failure to comply with an order shall constitute a separate
violation.
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are corrected.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
cc: Buddy Martin, Building Dept.
cc: Cotuit Fire Dept.
cc: Marion Newton tenant
ai SENDER: I also wish to receive the
C ■Complete items 1 and/or 2 for additional services.
w ■Complete items 3,4a,and 4b. following services(for an
d ■Print your name and address on the reverse of this form so that we can return this extra fee):
card to you. t ' N
j ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address
L permit.
m ■Write°Return Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery W
t ,;The Return Receipt will show to whom the article was delivered and the date a
delivered. Consult postmaster for fee.
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PS Form 3811�t'D camber 1994"='' { I i f: i •:i t.DomesticiReturn Receipt
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UNITED STATES POSTAL SERVICECQQ O 0St-e1`35
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`g Health Department
' Tom of Barnstable
P.0.Box 534 i
Hyannss,AMasSachusetts 02601
Fax(508)775-3344
' Phoms, (508) 790-6265
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Receipt for
Certified Mail
SE No Insurance Coverage Provided
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to Whom&Date Delivere jar
Return Receipt Showing to
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Date,and Addressee's Address
TOTAL Postage
&Fees Is
Postmark or Date
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.postniarked,stick the gummed stub to the right of the return address
leaving the receipt attached and and present the article gat a post office service window or hand it to
your rural carrier(no extra tchaigej'� 4
2. If you do not want this e,ceipt postmNed,l stick the gummed stub to the right of the return
address of the article,date detach and-retain thelreceipt,and mail the article.
3. If you want a return receipt,write the certified mail number and your name and address on a
return receipt card,Form 3811,and,attacti 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 RETURN RECEIPT
REQUESTED adjacent to the number.
OD
4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee, M
endorse RESTRICTED DELIVERY on the front of the article. E
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5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If LL
return receipt is requested,check the applicable blocks in item 1 of Form 3811. U)
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6. Save this receipt and present it if you make inquiry. 1056o3-4--B-o21e
f'
L Town of Barnstable
Health Department
367 Main Street, Hyannis, MA 02601
Office 508-790-6265 Thomas A. McKean
FAX 508-775-3344 Director of Public Health
February 29, 1996
M.S. Katherine Hayden
160 Pine Street No. 20
Newton, MA
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 150 School Street, Cotuit was inspected on
February 23, 1996 by Jerome Dunning, Health Inspector for the Town of Barnstable
because of a complaint. The following violations of the Town of Barnstable Rental
Ordinance Article 51 and the Sanitary Code II were observed`
410.481: The owners name, address, and telephone number was not posted near the
main entrance of the building.
410.482: No Smoke detector provided.
410.450: No second means of egress provided.
You are directed to correct the violation of 410.482 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, this violation
must be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. Each separate day's failure to comply with an order shall constitute a separate
violation.
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are corrected.
PER ORDER OF THE BOARD OF HEALTH
'�A�omas�AWKean
w
Director of Public Health
cc: Buddy Martin, Building Dept.
cc: Cotuit Fire Dept.
cc: Marion Newton tenant
f
Wtf14RAel.R
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Town of Barnstable
Health Department
367 Main Street, Hyannis MA 02601
',• *4hoab A& McKean
officer 508-790-6265 biNotot of Public He
FAXt 508-775-3344
AS ,+
' NOTICE TO ABATE VIOLATIONS
ooFl05 FITN�ESS41FOR HUMAN HABITATION
CODE II MINIMUM
AND THE TOWN OF B1IRNSTABLE RENTAL ORDINANCE ARTICLE 51
�`°��' sT. was
The property owned by you located. at P�,ao„ ealth Inspector for
inspected on �,�.3 -9� bY�
the Town of Barnstable, be ause of a complaint. The
following violations of the Town of Barnstable Rental
Ordinance Article 51 and the Sanitary Coe II were observed:
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You a.re directed to correct the
this notice
of
within twentyfour (24) hours of receipt
Of You are also directed to correct the remaining f this liee�
violations within seven (7) days of' receipt v
ing
You may request a hearing rd of tten Nealthetition wit in reAven t 17)
same is received by the Boa
days after the date order is regardlessed. However,of any request forsa
violations must be corrected
hearing.
please be advised that failure to comply with an order Could
result in a fine of not more than $500. Each constitute aaateparatse
r.ailure to comply with an order shall
violation.
You are also subject to a on-c$15 00 nal cfvritvea h f additional
$40.00 for
the first violation
violation. Tickets wil be issued daily until the violations
are corrected.
pER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
TOWN OFB RNST BLE
LOCATIONISO
"'� wee SEWAGE #91'
VILLAGE ASSESSOR'S, MAP & LOT® — O
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY1.
LEACHING FACILITY.(type) ► (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBL C WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: t Y.
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
r
TOWN OF BARNSTABLE
Appliratiun for Biupuuttl Work,5 Tomarnriiun Vanfit
Application is hereby made..for, a-Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.. —5 ......5 : ...........-s........: d__... ......
.. ............g ...-. . _ ..................................
Lo tio`^Add,ce� ,(� , SG Lot No. `
.Lf, V..vl..�........
-- 1- ��4 ------ --...1..... ...... --------- ---- ----.................:......
ner tress
......._....
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
ps Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Ga Other fixtures ------------------------- ---••- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length.........._......... Total leaching area....................sq. ft.
Seepage Pit No---_---------------- Diameter______..____________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�1, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ---•------•---------------------------------------------•--•----------•-._..._...------•-•-----••---.........................................................
0 Description of Soil___________ ___ ------------------------------------------------------------------------------------------------------------------------
---------------------------• .....................................--•------••-----------------------••-------------------------------------------•--•--••••----------•-•------•------ - --- --•-f
U Nature of Repairs r Alterations—Answer yvhen pplicable_ ______ ..�.eS:�-" -_..._. L•_ ---_S__C` -__
-----•--
Agreement: 1000
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State En vir mental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Co T
lia cceAh�s been issued by the board of he Ith.
Signe -- - � = A— I I I
---- ---------------------------------------------------------------------- --------- ........................................
Dace
Application Approved By --------------- � - ---- ...�a
. --------------------------------------------------------------------------- Dale
Application Disapproved for the following reasons- --------------------- -- --------------- --.-.-.......-------.........-....----........------------------
------------------ ....................................
Permit No. ....J---f_ �GP Issued `)' 1 `� o I Date ....
- - ------
--------------'------"----------.._-----'----..--.... Dare
Ni— r=�—
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a TOWN OF BARNSTABLE
Appliratinn for Disposal Works Tnnstrnrtinn thrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system. _�.?. 0........I . .... . .. .. ...... -...........
_'.�. .._
' n .....--•Lo lion-Addr ss SG - Lot No.
•-�-� -} -- - -P ....................... .... ................................-.
W �.Owner Address
.._ . .�r._�.��........... ...1.. m�=.�.......5d :....... tit s -� .....
Installer Address
UType of Building ^� Size Lot............................Sq. feet
Dwelling—No. of Bedrooms......._.J..................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g •--------------------------- P ( ) •— Cafeteria-( )
Otherfixtures ------------------------------------------------•-----.--••••......••-•---•--•----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid*capacity............gallons Length.............•.. Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date...................
..._...
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water- _____._........__.
LT, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
Pi ---------------- -----------------•-----•------........--------.....-------•-••-•-•---•-----................................................................
0 Description of Soil........... ...... ___
x ..--..-•.............................••_..�-��:�. --...
W
VNature of Repairs Tr Alterations—Answer when pplicable----------- _ ____. ...... V-___ -
Agreement: l oc�o C_ l o o U st
-The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
' system in operation until a Certificate of Con lia ce h s be_en issued by the board of health.
Signed -- _.` !..\--------.-.J ----:- a l "
.........................
� Date
Application Approved B J--.. r�a_.:h_ ---
............................. Date
Application Disappr ed for the following reasons- --------------------------------------...............-- -- ---------------------------------------------------------------------
� -----��- --.��(. '---------------------------------------Issued ..�...�'....~.�.� ^� 91
' Date
<� Permit No. Date
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gertifira e of C ontlatiance f
a, 1/
TI qS IS TO CERTIFY, That the Individual Sewage Di osal System constructed ( ) or Repaired ( )
" Installer
at .,---------- .....--...-S.. `..`r m �. - .. ' `"`.t....-..
has been installed in accordance'with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ....-�/....... ............. dated ..........................---....--..........--.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED_ AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION S ISFACTORY.) 1' ,I
DATE------.. .........................................( � � .......� Inspector j f f(� ....1. ... .
.r
--- '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE k,
No...�l.-.SG FEE...... / . ..
Mop nrko Tnnn#rnr#inn r Ti#
Permission is hereby ranted.___���1�..�'..�_.�. D ``-' ��'`J ` �1'S
Yg _ ....... .............. •.... •---.......
to Construct ( ) or Repair ( L)-a:ff ndividual Sew age DL'Tosal System
at No r �-
Street qq r qq
as shown on the application for Disposal Works Construction Permit No._!.�' �`�_ Dated....... .7_, �....
(� �'-.�....................................................
-
1 q 1✓ Board of Health
DATE••.I .....................................................
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
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TOWNrOF 7,NASABLE
LOCATION �v( SEWAGE # /
VILLAGE cC4 Cti� 4 ASSESSOR'S MAP & LOTPaQv
IS
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) L (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER C-p,�
DATE PERMIT ISSUED: I — 9 f - .
DATE COMPLIANCE ISSUED: / ;Z,3 -- /
VARIANCE GRANTED: Yes No
6