HomeMy WebLinkAbout0791 PITCHER'S WAY - Health 791 PITCHERS WAY, HYANNIS
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is
required for HYANNIS MA 02601
every page. City/Town 10/20/09
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
'mPOrta"``
When filling out A. General Information
forms on the r /�
computer,use 1. InspeCtor. )"I I/►
only the tab key
to move your DOUGLAS A BROWN
cursor-do not
use the return Name of Inspector
key. DOUGLAS A. BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
City/Town State
Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
CG
q Passes ElConditionally Passes ElFails
64
._ ❑ Needs Further Evaluation by the Local Approving Authority
Ez
.0
co
LL-: /20/09
inspector's ature Date
The;system inspector shall submit a copy of this inspection report to the Approving Authority(Board
a W-Hbalth or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
II
t5ins•09jD8 Title 5 Official Ins pection Form:SubsurfaISDisposal t m• age 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 791 PITCHERS WAY
Property Address
L'UCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601 10/20/09
every page. Cltylrown State Zip Code
Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•0908
Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r—
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is
required for HYANNIS MA 02601
09
every page. City/Town 10
State Zip Code Datea o of f Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructedpipe(s). T
s stem will ass inspection if with a he
y p P ( approval of the Board of Health):
❑ broken pipe(s)are replaced ElY ❑ N ❑ ND(Explain below):
Elobstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
791 PITCHERS WAY
Properly Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601
every page. City/Town 10/20/09
State Zip Code Date of Inspection
B. Certification (cont.)
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 at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure Criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ . ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than Y day flow
i t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601
every page. City/Town 1
State Zip Code Dateate o of inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ 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 fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. 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.
For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
{
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
791 PITCHERS WAY
Property Address
LUCI EN
Owner Owner's Name
information is HYANNIS required for MA 02601 10/20/09
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS).on the site has
been determined based on:
® ❑ Existing information.'For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 8 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880
t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601
10/20/09
every page. Cltylrown State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 2000 GALLON TANK D-BOX AND
TWO LEACH PITS
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): 07-549 08-587
Detail:
Sump pump?
❑ Yes ❑ No
Last date of occupancy: CURRENT
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09M .
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'Y 791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601 10/20/09
every page. Clty/rown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
El Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page a of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601
every page. Cltyrrown 10
State Zip Code Datea of of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
1985 ACCORDING TO PERMIT
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene
El other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 2000 GALLON
Sludge depth:
t5ins-09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601
every page. City/Town 10
State Zip Code Datee o of f inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK COULD USE PUMPING AT THIS TIME
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
NOW Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601
every page. cityrrown 10
State Zip Code Datee o of f Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disp
osal posal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"t 791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601
every page. City/Town 09
State Zip Code Date
ate of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
11
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.):
SLIGHT SOLID CARRY-OVER INTO BOX
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 12 of 17
ill
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ar 791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601 10/20/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation,etc.):
BOTH PITS ARE A HALF FULL AT THIS TIME STAIN LINES APPEAR TO BE AT LIQUID LEVEL
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 791 PITCHERS WAY
Property Address
LUCI EN
Owner Owner's Name
information is HYANNIS
required for MA 02601 10/20/09
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5ins-09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
791 PITCHERS WAY
Properly Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601
every page. Cityrrown S 10 a of Instate Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
791 PITCHERS WAY
Property Address
LUCIEN
Owner Owner's Name
information is HYANNIS
required for MA 02601 10/20/09
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
rY 791 PITCHERS WAY
Properly Address
LUCIEN
Owner Owner's Name
information is HYANNIS required for MA 02601 10/20/09
every page. City/Town State Zip Code
Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary:A, B, C, D, or E checked
❑ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
❑ System Information—Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09M Title 5 Official Inspection Form!Subsurface Sewage Disp
osal posal System•Page 17 of 17
L0' .AT10N� ?% SEWAGE PERMIT NO.
VILLAGE "
I N S T A LLER'S NAME i ADDRESS
�e�6+'i`..!`�E: ¢..,a' F--4.*` l! by�r 6- ` r✓�e'`�.° -
�' a UILDE R OR OWNER
DATE PERMIT ISSUED
DATE C0"MPLIANCE ISSUED
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L0' A T ION 23 / S E'W A G E PERMIT NO.
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VILLAGE
Hqa,4)A1t--<. Ma
IN-ST"A AEFUS NAME & ADDRESS
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R U I,l D E R OR OWNER
r
DATE PERMIT ISSUED
DATE C0WPLIANCE ISSUED
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BOARD OF HEALTH �
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TIIIS IS' TO CERTIFY, That the In"vidual S Vk"a a Dis)osal Sistcm cunt-nn-ted
Uaired
nsfa r
at............. .... .
has been installed in accordance with the provisions of TIT,�Z rl
lye State 5anitaly (:',)d as Ir,c rile-A in application for Disposal Works Construction 1 ermit `'o....."!:�� - t c
atd
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON RU ® AS`A Gu� A tEE;T1�/►T T
J .d. ..
SYSTEM WILL FUNCTION SATISFACTORY. HE
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OL 7 1-/S1 $ :56drvomS _._.. _......._.__ . .... . __
LAT ION
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of / 7F/ SEWAGE PERMIT 140,
VI'LLAG £ s
H Ll a-IAV
m a •
IN, STA LLER'S NAME i ADDRESS
�`�,�Cl'i'�•.�-%� des•��..
a UfLDER OR OWNER
DATE PERMIT
ISSUED
DATE COMPLIANCE ISSUED
q
3
(PSI '
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
Date
Owner pyti YL Tenant
Address 1 1 �l'-( l45s Oky 7 Address
Compliance Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities
J
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities ✓ _�1 ..
8.' Ventilation
9. Installation and Maintenance of Facilities
G rc1:�`S
10. Curtailment of Service N (0-- G SMc `FQC '"
11. Space and Use S c�
12. Exits
13. Installation and Maintenance of Structural �GPo11srre
Elements -q'[td ch S�vLQ T2CTac�
14. Insects and Rodents V/
15. Garbage and Rubbish Storage and Disposal / l
V
16. Sewage Disposal `
17. Temporary Housing
PART II
37. Placarding of Condemned Dwelling; /J A'
Removal of Occupants; Demolition
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
HOBBS&WARREN.INC. �_
...Approved:��• Z %��oa
TOWN OF BARNSTABLE /--�
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date ! 2 �11 , Og Time: In Out 2 ' Gv
6m►nEr E�iNt v NO Ly n►w Tenant
Address Gj ( 6 1"Tc. fvt—S w Address
xy A-gkjS MA •
Compliance Remarks or
Regulation# Yes,j NO Recommendations
2. Kitchen Facilities v��'t s �r��� w►�c w�
O k L _ N o Cp N►ww» 1X_\-te
3. Bathroom Facilities ' O S 1 cC..4X�co
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal M
16. Sewage Disposal eiv4-i r&-
17.Temporary Housing
18. Driveway Width
19. Number of Tenants Observed
PART II .
37. Placarding of Condemned Dwelling; v s7 G S-r
Removal of Occupants; Demolition �,a..�► S
Number of Bedrooms S Number of Vehicles Allowed (max)
Number of Persons Allowed (Max) NA (to )o ) 00,
(o ;•Odk w Qo ors,
Person(s) Interviewed Inspector ZA.
-17"/Y'
If Public Building such as Store or Hotel/Motel specify here
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
Date
Owner 1 i Tenant
Address 1I b` Address
Compliance Remarks or
Regulation# Yes N Recommendations
2. Kitchen Facilities
3. Bathroom Facilities PLO"F Q/.' Dve p_
4. Water Supply 1
5. Hot Water Facilities
6. Heating Facilities ov v-a�-
7. Lighting and Electrical Facilities 1�
8. Ventilation A�0'
9. Installation and Maintenance of Facilities V y� 45
10. Curtailment of Service A/
11. Space and Use C
12. Exits — j
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents ��
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17. Temporary Housing
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Person(s) Interviewed ` Inspect
If Public Building such as Store or Hotel/Motel specify here
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TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date 2 6 q1 Z00-7 Time: In /6•'/ Out �l' ou 'GL
Owner � 1-14 d,6 P4 GNEc 0 Tenant Z 0 041,v ej l ld v 5
Address f'9ug--,s )Z Address
1—
G�,��`r��,��c �n vZ&ZA Ma our f
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities r4" L-'
S E� GKt�p^FN7
3. Bathroom Facilities
4. Water Supply TO L---j
5. Hot Water Facilities N S.
c7 T l�CL
6. Heating Facilities ac--rvz�
7. Lighting and Electrical Facilities f
Nei
8. Ventilation
V ®Y s✓4
9. Installation and Maintenance of Facilities Z _ V-
10. Curtailment of Service -2. — O V-
11. Space and Use u Q
12. Exits ✓ U �"
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents A°" ti R t L0
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17. Temporary Housing
18. Driveway Width
19. Number of Tenants Observed S
PART II
37. Placarding of Condemned Dwelling; R19 2 � T
Removal of Occupants; Demolition
Number of Bedrooms 4, - Number of Vehicles Allowed (max)
Number of Persons Allowed (max)
Person(s) Interviewed Inspector r S.
If Public Building such as Store or Hotel/Motel specify here
TOWN OF BARNSTABLE
t�
1
BOARD OF HEALTH
ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION
�olqDate
Owner Tenant
Address WAYAddress
Compliance Remarks or
Regulation# Yes No Recommendations
2. 'Kitchen Facilities
3. Bathroom Facilities
4. Water Supply V,
5. Hot Water Facilities / ! O or
6. Heating Facilities NA,
7. Lighting and Electrical Facilities
8. Ventilation
o
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents R-f6--
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal �i v
17. Temporary Housing v
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
o G
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
HOBBS&WARREN,INC. /
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
r
Date /
Owner Tenant
qbj 6r I
f
Address CJ WA\ Address
117 Complionce Remarks or
Regulation k Yes No Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply 1 D
5. Hot Water Facilities i40
�//ll�
6. Heating Facilities ' /`�f
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities SO
� nl�/1
10. Curtailment of Service �(J /" V
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17. Temporary Housing
PART 11 � BeA .
I
37. Placording of Condemned Dwelling; A
Removal of Occupants; Demolition
p e
Person(s) Interviewed 4zmj Inspector
If Public Building such as Store or Hotel/Motel specify here
HoBBs IN WARREN.INC.
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
W
Date
i I—
Owner AMTenant
1�.
Address Address
Compliance Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities / O
6. Heating Facilities
7. Lighting and Electrical Facilities !/ Z
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements /
14. Insects and Rodents 4
1C
15. Garbage and Rubbish Storage and Disposal
QJ
16. Sewage Disposal Vr6 S0N
17. Temporary Housing
PART II (� / W, 1�C)
37. Plocarding of Condemned Dwelling;
Removal of Occupants; Demolition
c
Person(s)Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
HOBBS$WARREN.INC.
v TOWN OF BARNSTABLE
�� �„/G BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
J�o q
Date W
Owner I LUA rf) Tenant
Address WA \ Address
Compliance Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities A
3. Bathroom FacilitiesV/- A)P� )E
S �
4. Water Supply voo� 0WN
5. Hot Water Facilities E
oy
6. Heating Facilities
7. Lighting and Electrical Facilities
i
8. Ventilation
9. Installation and Maintenance of Facilities
/Al A
10. Curtailment of Service
11. Space and Use
12. Exits m o 0
13. Installation and Maintenance of Structural ft�
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal 08A AS:�;
16. Sewage Disposal
17. Temporary Housing
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
41WAV41�
o
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
HoBBs&WARREN.INC.
TOWN OF BARNSTABLE
' BOARD OF HEALTH
ARTICLE It:MINIMUM STANDARDS FOR HUMAN HABITATION
Date
Owner Q 1 1 Tenant
Address ` 11 b` Address
Compliance Remarks or
Regulation# Yes N Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use Cp
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and'Disposal
16. Sewage Disposal
r
17. Temporary Housing
PART II
37. Placarding of Condemned Dwelling; ry�i
Removal of Occupants; Demolition
Person(s)Interviewed Inspect
If Public Building such as Store or Hotel/Motel specify here