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Commonwealth of Massachusetts �7°2 r 16S
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Curry Lane u'
m
Property Address 9
Sharon Rusk E-•
Owner Owner's Name /
information is required for every Osterville ✓ MA 02655 8-22-16
page. City/Town State Zip Code Date of Inspection
t7?
Inspection results must be submitted on this form. Inspection forms may not be altered 99any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, `��``��y►OF,Wq v,,��i
use only the tab 1. Inspector:
key to move your 02;= • •�y
cursor-do not James D.Sears =�: JAMES `N
use the return _�' rn
key. Name of Inspector
� *py Na Enterprises, LLC �T �Q• "eta
r� Company Name �� r'•. RTtF� . O ���
153 Commercial Street
Company Address
Mashpee MA 02649
City/Town State Zip Code
508477-8877 S1623
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:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Ua6vie�
8-26-16
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 ofI17
A
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is required for every Osteryille MA 02655 8-22-16
page. City/Town 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:
® 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:
The system is three old block c. pools
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. R
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
yM 7 Curry Lane
Property Address -
Sharon Rusk
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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 obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-16
page. City/Town 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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
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 '/z day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
required fo is Osterville MA 02655 8-22-16
required for every
page. City/Town State Zip Code Date 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.
❑ ® 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
IMEMMEMI
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-16
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 uncovered, opened, and the interiorUMMIUMM
.inspected for the condition of the 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): NA Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 1'10 gpd x#of bedrooms): 330
t5ins.doc•rev.6/16 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
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is
required for every Osterville MA 02655 8-22-16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The systam is three old block c. pools.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2014-76,000Gais
g ( y g (gpd))' 2015-125,000GaI s
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: PresentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): cations 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 reading
s, if available.
t5ins.doc-rev.6116 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
-� 7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-16
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: 1000 Gal
gallons
How was quantity pumped determined? Gage on pump truck
Reason for pumping: Part of inspection
Type of System:
❑ Septic tank, distribution box, soil absorption system
In4)V
® AMocesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
NA -
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site,plan):
Depth below grade: 38"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.):
Pipeing is 4" PVC SCH -40 & Orange Burge.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
-, years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
4 - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is
required for every Osterville MA 02655 ' 8-22-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
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.):
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts .
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-16
page. City/Town State Zip Code Date of 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is required for every Osterville MA 02655 B-22-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No Box
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*,If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):,
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is required for every Osteryille MA 02655 8-22-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number:
2
❑ 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.):
Leaching is two 7' deep old c. pool's. Over flow# 1 at 40# below grade dry w/clean wall's. Over
flow#2 at 3' below grade dry w/clean wall's. No sign of over loading or high stain line.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
11-
Depth-top of liquid to inlet invert 20
Depth of solids layer 61
Depth of scum layer
1"
Dimensions of cesspool 7' deep
Materials of construction Block
I
Indication of groundwater inflow ❑ Yes ® No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
-/0 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
Information is required for every Osterville MA 02655 8-22-16
page. City/Town 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.):
Main pool 7' deep w/cover at 6". Pool at working level. One inlet, two outlets. No sign of over
loading. Pool was pumped as part of inspection.
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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
_ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is Osterville
required for every MA 02655 8-22-16
page. City/Town State 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
14
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C- 3 = 33
i 161n11-3/13 7'mr)(iorticiul lnsp:coon F turn:Subsurloco Sov4ge Disposal Syslom-Pago 16a 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
«., 7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
11'+
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:
Auger T.H. 4' below c.pool. T.H. at 11' no G.W..
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Curry Lane
Property Address
Sharon Rusk
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-16
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
SEWAGE INSPECTIONS (�
LOCA: "SON
�' � 7 Curry Lane DATE 10/29/02
VILLAGE Ostervil'�6=Mass. . ASSESSOR'S MAP & LOT 55
-IN8FkECTOR Joseph* P Mgoomber Jr
SEPTIC TANK CAPACITY None 3-5 'X7 ' bloc cPss=nnl
LEACHING FACILITY: (type) (size) 3 n p 0—GLS
NO. OF BEDROOMS 3
BUILDER OR OWNER Linda Cameron
OWNER MAILING ADDRESS
;Same as above
i
w / �
i �
DATE : 10/29/02
PROPERTY ADDRESS:7 'Cutry Lane
Osterviile Mass_-_-----_ �
02655
-------------------------
n the above date I inspected the septic stem at the above✓ad 0 � P P Y cRMEI!/ED
This system consists of the following:
1 . 3-5 'X7 ' block cesspools. NOV 12 2002
2 See page 10 -
TOWN OF BARNSTABLE
HEALTH DEPT.
Based on my inspection, I certify the following conditions-,
1
3. This is not a title five septic system.
4. This is a sewage system. _ . _ -- - - . --
[5: the sewage system is in proper working order nat-the -present;.7,,7,r,. f
6:—Pumped main cesspool at time of inspection. •
7 . Overflow dry.
8. 9-5 ' X7 ' cesspools Main actcs as a tank,one overflow to right
and one to the left.
SIGNATUR
— ——— MAP
Name : J . P . Macomber Jr .
-----------------------
PARCEL
Corripany :�os�ph Pam_ Macomf�er Son ,, Inc . LOT
Address :--BQx-Q_Q___ , ------
Phone:_-508- 775- 3338 ----
THIS CERTIFICATION DOES NOT CONSTITUTE. A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC. .Tan ks•Cesspools•Leachflelds
Pumped & Installed.
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632.0066
775.3338 775.6412
,per
-\ COMMONWEALTH OF MA.SSACHUSETTS
,r
EXECUTIVE OFFICE OF ENVIRONMENTAL, AFFAIRS'
DEPARTMENT DF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 7 Curry Lane
nG1-Prvi 1 1 Pi M3SS. ,
Owner's Name: Linda ("amernn
Owner's Address:Same
Date of Inspection: 1 0/29/02
Name of Inspector: (please print) Joseph P. Macomber Jr.
Company Name: J.P. Macomber & Sons Inc
Mailing Address: Box 66
Ct=nt-Pryi 1 + P Ma 2632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
I certih 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
:Tatnute and experience in the proper function ar:d 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:
asses
Condii na Passes
Needs Funher Evaluation by the Local Approving Authority
— Fails
Inspector's Signature: 4111,06Date:
The system inspector shall mit a copy of this inspection report to the Approving Authoriry(Board of Health or
DEP) within 30 days of compleiing Lhis inspection. If the system is a shared system or has a design now 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 o4vner and copies sent to the buyer, if applicable, and the approving
authoriry.
Notes and Comments
"This report only describes onditions ot•Che•time of inspection and under the conditions of use athat
time. This inspection does not address how the system will perform in the future under the same or differeot
—--conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) `
Property Address: 7 Curry Lane `
osterville.mass.
Owner:T.i nda C'amarnn
Date of Inspection: 10 f 2A/n 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all-of Section D
A.qy Pa
� e not foundaninformation hick indicates that any of the failure criteria described in 310 CMR
I5.303or m 31 MR 13.304'exist. Any failure criteria not evaluated are indicated below:
r Comments:.,.,,—
The
sawaCle system is in proper working order
�;at the presant times f ,
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the'following statements. If"not determined"please
explain.
��� The e tic 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:
`/&tom Observation of sewage backup or break out or high static water level in th istribution boxldue to broken or
obstructed pipes)or due to a broken,settled or uneven distribution box..System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain: r
/0 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 I I
F .
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7 Curry T.anP
0 w n e r:L�.i nda rayon
Date of Inspection: jW'/2g /n2
C. Further Evaluation is Required by the Board of Health:
XO 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.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in it manner which will protect public health, safety and the environment:
�a 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:
WThe system has a septic .tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or rributary to a surface water supply.
0(0 The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple.
. 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 tang and SAS and the SAS is less than 109 feet but, O feet or more from a
private water supple wellI• Method used to determine distance f
'•This s\stem 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 artached to this form.
<3. Other:
_.,iTKks is sewage system Main -cesspool acts a �
`" Septic tank_ Solids are held ; n place and the effluent �
naqqPq fin fihP fiwn nyerf 1 nw r'eSS.pC1C�1S. `'
.. e
3
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:7 Curry Lane
Osterville,Mass.
Owner: T.i nrla CamPrnn
Date of Inspection: 1 0.12 4.112
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
_ j//�ackup 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 th istribution bo above outlet invert due to an overloaded or clogged SAS or
��- cesspool
✓ squid depth in cesspool is less than 6"below invert.or available volume is less than ''day flow
equired 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.
Arty portion of a cesspool or privy is within a Zone 1 of a public well. i
,Any portion of a cesspool or privy is within 50 feet of a private water supply well.
cc_//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.).
(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/
V the system is within"400 feet of a surface drinking water supply
_ _ the system is within 200 feet of 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 app.*opriate regional office of the Department.
4
Page S of
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Properry Address: 7 C
0wncr: Li ad C'amAr_o
Date of lospectioo:
Check if the rollowina have been done. You must indicate ' s': or"no" as to each of the following:
Yes ';o
Pumpvtg information was provided by the owner, occupant, Or Board of Health
ZA,erc am of the system components pumped out in the previous two weeks
Has the system received normal (lows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as pan of this inspection ? -
/Were as built plans of the system obtained and examined? (If they were not available-note as 'rA
�z_ Was the facility or dwelling inspected for signs of sewage back up
was the site inspected for signs of break out ^
_ Were all system componcnts.,.excluding the SAS, located on site
Were the septic Lw-kk anholes uncovered, opened, and the interior of the tank inspected for the condl:.o
of!^e baffles or tees, mate— riTof const-action, 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 si sAage disposal systems ^
The size and location of the Soil Absorption System (SAS) on the site has been determined.based on
Yes no�
f/ Existing`inforination. For example, a plan at the Board of Health. ^
61--7 Determined in.the^Field ('if any of the failure criteria related to Part C is at issue approximation of d:s=n:c
s ;nacceptable) 1310 CMR 1 5.30.2(3)(b))
l
Page 6 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7 Curry Lane
Osterville,Mass.'
Owner: Linda Cameron
Date of Inspection: 10 2 9/0 2
FLOW CONDITIONS
RESIDENTIAL n
Number of bedrooms(design): J Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: l 10 gpd x 4 of bedrooms):
Number of current residents: v
Does residence have a garbage grinder(yes or no):Yps
Is laundry on a separate sewage system (yes or no):Ad (if yes separate inspection required]
Laundry system inspected(yes or no):/40;
Seasonal use: (yes or no): tr�d e
Water meter readings, if available(last 2 years usage(gpd)): 2000-1.04, 000 gallons=284 . 94 GPD
Sump pump(yes or no): 2001 -1 39,000 gallons_=380.83 GPD
Last date of occupancy: Sprinkler system is present.
COMM ERCIAL/WDUSTRIAL
Type of establishment: A,/A
Design flow(based on 310 CMR 15.203): fi gpd
Basis of design flow(seats/persons/sgft,etc.): /JA
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no): 4M ,
Non-sanitary waste discharged to the Title 5 system (yes or no):A/V
Water meter readings, if available: AIX
Last date of occupancy/use: _
OTHER(describe): /UA
GENERAL INFORMATION
Pumping Records
Source of information: A" )9v°,4ij,9)2).P�
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:Maint. Ckecked main pool structurai conctition. No
signs of water intrusion.Cesspools are structurally sound.
TYPE OF SYSTEM
y� Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
,L&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)
.Jfd Tight tank /tk Attach a copy of the DEP approval •.
/LL Other(describe):
Approximate age of all components, date installed(if known)and source of information:
ors ,
Were sewage odors detected when arriving at the site(yes or no): .E/e
6 .
Page 7 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 Curry Lane
Owner: Linda Cameron
Date of Inspection: 1 0/2()f 02
BUILDING SEWER (locate on site plan) Fromthe house to the main
;r cesspool. ( Cast iron and 4"
Depth below grader /+ orangberg pipe) Lite weight
Materials of construction: ,/cast iron ,�40 PVC t� other(explain 11 pipe. Though out the
Distance from private water supply well or suction line: l/�, �� remainder of the system.
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight-No evidPncP of leakage_ThP Gystem
is vented through the house vents.
SEPTIC TANK*4�• (locate on site plan)
Depth below grade:
Material of construction:4kconcreteekmetal (,4 ,fiberglass4lSolyethylene.
tiother(explain) 1414
If tank is metal list age: r4 is age confirmed by a Certificate of Compliance (yes'or no)4A/ (attach'a copy of
certificate)
Dimensions: �r�A
Sludge depth:
Distance from top of sludge to bonom of outlet tee or baffle:
Scum thickness: AAA
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: A✓� ,
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.),,:.�„
Sept1C tank is not prPSPnt_ Main r`ec;-,pnn1 Ghntil r] hp— piimpPrl aXlnual7 y:
(Garbage disposal��is=presen�� ,�,�
GREASE TRARUYe(locate on site plan)
Depth below grade:,Vl�
Material of consrruction;/t%9 concretei//i9 metal4/rs7 fiberglass�_�olyethylene/P other
(explain): — —
Dimensions: A .
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: eG4
Distance from bonom of scum to bonom of outlet tee or baffle:
Date of last pumping: 4441
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 tray is not- present.
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: 7 Curry Lane
Osterville,Mass.
Owner: Li nda Camerm
Date of Inspection: 1 ().19 c)./
TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:_V
Material of construction:�gconcrete eAmetalA fiberglass�olyethylene4�4 other(explain):
Dimensions:
Capacity: gallons
Design Flow: gahons/day
Alarm present(yes or no): ,�)X
Alarm level:� Alarm in working order(yes or no):,e�A)
Date of last pumping: AA—
Comments(condition of alarm and float switches,etc.):
Tight or holding tanks are 'not present
DISTRIBUTION BOX (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_ 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 CHAMBERe".(locate on site plan) i
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.):
Pump chamber is not present.
8
Page 9 of 1 1
,
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 Curry Lane
Osterville,Mass.
Owner: Li nrla Cam _ on
Date of Inspection: 1().19 g I n
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
3-51XV block cesspools.
If SAS not located explain why:
Located see page 10
TrUd yppe -
leaching pits, number:Q
46 leaching chambers, number:
leaching galleries,number ej
:
l leaching trenches,number, length:
�t� leaching fields,number, dimensions: ,
overflow cesspool, number:'
.00 innovative/alternative system Type/name of technology:Lr ";.�A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil„condition of vegetation,
etc.):
Loamy sand to medium fine sand No signs of hydraulic failure or
„ a are dry-Vegetation is normal
ponding-Sails
CESSPOOLS: cesspool ust be pumped as pan of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer.
Depth of scum laver.
Dimensions of cesspools
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.):
Same as above
PRIVY4,�f (locate on site plan) Y
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a
9
Pr;f 10 0/I 1
OFFIC!,ti INSPECTION FOR�4 — NpT FOR VOLLJNT
SUBSURFACE SEWAGE DISPOS,_, SYSTEM JNSPECrjjpNEFpFZM~ TS
PART C
SYSTEM INPOP-M-ATION (conlinvco)
➢,�� � �aa �„ 7 Curry .Lane
ervi
Disc of Inip�ci o0
S>LTCH Or SEWACE DISPO�AI SYSTEM
i iilicn or inc ir.ilc oilpolll lyllcm In(Ivdln� II(1 IQ II I(I11 r,
loe d
iu ",.li, w„n,n IOJ lccl. Loi( wl+crc pvbIi( wIItI 1 Opl(TTltntnl f(ftrcncc I
p9 Y cnlcrt IAc bviloln(
� Carr y /�r►� , OS{{rvrlly
Lj
CIA
aL
M
Page I I of I 1 -
41
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) r .
Property Address: 7 Curry Lane
Osterville,Mass.
Owner:Linda Cameron
Date of Inspection: 1 0/29/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
1
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
U(Z Obtained from system design plans on record • If checked, date of design plan reviewed: NA
YES Observed site(abutting property/observation hole within I50 feet of SAS)
N.o-_ Checked with local Board of Health-explain: NA
YES Checked with local excavators, installers- (anach documentation)
YES Accessed USGS database-explainbttp• //town barnstable,ma.ms..
You must describe how you established the high ground water elevation:
:ed; Gahrety & Miller Model-Ground water eleva ions above sea level
:ed; USGS' Observation well (3ata TtmP 1992
:ed: USGS; Tarhnirnal bulletin 92-000-1 Plate #2 January 1992 Annual
To n
ranc�eG of g�otitid water elevations,
-5 'X7 '
lock
i
esspo is �9 eet
Groundwater:"' Feet Be!ow Bottom of Pit High Ground g Adjustment 1..8 ft per Frimpter Method
Therefore, the vertical separation distance between the bortorr�
of tine leaching pit and the adjusted � G
groundwater table is lG'feet.
e
11
'I'•�'1T^M1I•fT^TT—\l"T.—T'rt i:".l'a'TI'.T..Tr:•.T•+'rTT:. �I` -tTTTI fTT1T�1't�rJ'1Z ..
'TOWN OF Barnstable WARD OF HEALTH 1
3UNSURFACE 9FWA(;E DISF'OSAL SYS'I'F;M INSPECTION FORM - PART D •- CEfr'1'IFICATION
•.•r+z-T•••..:r—*.i••-.-r.'•..r..-m•r-:•.r:r'�rr.r.-irrrr..".-.'--•.�-•::-'-�:.lr--r'*:-rw'.-*r n*"mrtnsv�rvrs r�nn�mrwt�t�-r' ,�
-TYPE OR PRINT CI.EARL1'-
PROPERTY INSPECTED
STREET ADDRESS 7 Curry Lane Osterville,Mass.
ASSESSORS MAP , DLOCK AND PARCEL
OWNER' s NAME Linda Cameron
PAJ?T D - CERTIFICATION I
NAME OF INSPECTOR Joseph P. Macomber Jr
COMPANY NAME Joseph P. Macomber 8,-�6n Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Street Town or City - Stat• CIP
COMPANY TELEPHONE ( 508 ) 775-3335 FAX ( 508 ) 790-1.578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage dieposa7 system at
this address and that the information reported is true , accurate , and
omplete as of the time of , inspectlon .. The inspection was performed and any
recommendations regarding u,�gre�de , Inc intenance , and repair are consistent
with my training and experience . in the proper function and maintenance of on-
site sewage disposal systems ,
Che/c one :
i ✓ System PASSED -
7.
The inspection which, I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the 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 FAILEU*
The inspection wiJicl) I 1lfive conducted has found that 'the system fails to
protect the public health and' the environment in . accordance with Title
5 , 3.10 CMR 15 - 303 , and as specifically noted on PART C -' FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
onecopy of this ce ification must be provided to the OWNER, the BUYER
where applicable ) and the DOARD OF 11LAL'111 ,
* If the inspection FAILED , thL ol4ner or " 'P' arator shall upgrade ' the eyetem
within one year of the date of tie inspection , unless allowed or required
otherwise as provided in 310 C!•IR -' 5 , 305 .
partd . doc
THE FOLLO WING
IS/ARE THE BEST
IMAGES FROM , POOR
QUALITY. ORIGINALS)
IM F L
DATA
Town of Barnstable Barnstable
�P�pF�HE Tp�p h Regulatory Services Department, 1'merisa�Ci,i
• BARNSTABLE, I
MASS.. m
i63q. Public Health Division - - 2007
dp 10
ArF0 MAt A, 200 Main Street, Hyannis MA 02601
email: Barnstable.Rental.Registration@town.barnstable.ma.us
OFFICE: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
APPLICATION FOR RESIDENTIAL RENTAL REGISTRATION
Date:
Fee: $00.00 Per Unit-Plus$25 for
each addtl.unit on the same parcel
Property Location:
UNIT# ' If Applicable, BUILDING#
Assessor's Map and Parcel:
Total Number of Rental Units You Own At This Property(including this unit).
Owner's Name:
. ,
Telephone Numbers r (Da
e u.s.POSTAGE>>PITNEV BOWES
Town of Barnstable °
Public Health Division ®
° ,�
® o
200 Main Street ZIP 02601 $ 000.48
Hyannis,MA 02601 �� � .
02 1W
0001.38.3424 JUN, 18,. 2015.
Sharon L. Rusk
1800 Old Meadow Road, Unit# 1011
McLean, VA 22102
*Inspections Done Annually. Applicant's Signature
Q:\Application Forms\RentalRegistAppForm w 25 fee Oct 2013 ltrhead.doc PAGE I
OF 2
INSTRUCTIONS ON PAGE 2