HomeMy WebLinkAbout0022 FINGER LANE - Health (2) f Fin er Lane..
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Commonwealth of Massachusetts �/tiq fi
Owner Title 5 Official Inspection Form ✓/
information is Subsurface Sewage Dispos y e Form - Not for Voluntary Assessments
required for every
page. 6A�Finger Lane(aka 22 Finger Lane)
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town 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.
Important:When filling out forms A. General Information
on the computer, TU
use only the tab 1. Inspector:
key to move your
cursor-do not Carmen E. Shay
use the return
key. Name of Inspector
Shay Environmental Services, Inc.
ran Company Name
P.O. Box 1576
Company Address
er, Mashpee MA 02649
City/Town State -Zip Code
508-539-7966 3080
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
4/27/18
Inspector'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 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.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 \
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i
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane(aka#22 Finger Lane)
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
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:
® 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:
System consists of a 1500 gallon tank and two leach pits.
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-11/.10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of W
f
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane (aka#22 Finger Lane) -
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town State Zip Code Date of 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 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane (aka#22 Finger Lane)
Property Address
Leon & Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
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 1/2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane (aka#22 Finger Lane)
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
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-
1 0,000g pd.
❑ ® 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane(aka#22 Finger Lane)
Property Address
Leon & Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
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.Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane(aka#22 Finger Lane)
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town State Zip Code Date of Inspection
D. System Information
Description:
Tank, D-Box and Two-6'deep by 6'diam pit with 2 feet of stone around present.
Number of current residents: 0
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)):
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:
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane(aka#22 Finger Lane)
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18.
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Current
Date
Other(describe below):
i
General Information
Pumping Records:
Source of information: Board of Health
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.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane(aka#22 Finger Lane)
Property Address
Leon & Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1986 per plan on file at the Board of Health
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2 6
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20
feet,
Comments (on condition of joints, venting, evidence of leakage, etc.):
No evidence of leaks, plumbing properly vented.
Septic Tank (locate on site plan): .
Depth below grade: 1
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: 5'x 5'x 10"
Sludge depth:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane (aka#22 Finger Lane)
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 23
Scum thickness 1/2
-
Distance from top of scum to top of outlet tee or baffle 4"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measured
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 in good condition. Inlet and Outlet Tee in good condition
Grease Trap (locate on site plan):
Depth below grade:
feet -
Material of construction:
❑ concrete ❑ metal ❑fiberglass El 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-11/10 Title 5 Official Inspection Form:Subsurface SewageDisposal System•Page 10 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane (aka#22 Finger Lane)
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town State 2 ip 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•11/10 ' ' Title 5 Official Inspection Form:Subsurface SewageDisposal System-Page 11 of 17
t
i
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane (aka#22 Finger Lane)
Property Address
Leon & Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town 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
D-box Present
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.):
one outlets present to leach trench. no evidence of backup noted or of any carryover.
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•11/10, Title 5 Official Inspection Form:Subsurface SewageDisposal System•Page 12 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane(aka#22 Finger Lane)
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits - number:
2-6x6 w/2' stone
❑ 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.):
Opened pit cover and found 3' liquid in both pits No evidence of backup noted.
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane(aka#22 Finger Lane.)
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town State Zip Code Date of Inspection
Indication of groundwater inflow ❑ Yes ❑ No
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•11/10 Title 5 Official Inspection Form:Subsurface SewageDisposal System-Page 14 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane (aka#22 Finger Lane)
Property Address
Leon &Shirley Jaffe
Owner's Name
Osterville MA. 02536 4/27/18
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
j��'QR'N OF BARNS?Aff LE
G'CATiON Gs0�t0 f'�n t`t- //j%1_%- SE.N'AOEN..-.®./
L`4STALLER'S NA.ME m PNO?SE NO.._... .._,._ _L�'1-d 4A-tl tl 1
SEI"11C TANK CAPACrry_ reD
LEACFUNG FACa.rrt.(t)'pei07— /'1Jj, �Cc �.1(Y-a;,,aj /7b_ -
NO.OFBFDROOhiS.
BMDER OR OWNER 4.GbFi1 .
PE1Li1ITDATE: coN1PLIANCE OATS: ..�••
Seputdan.Dis•„urse Between the:
43axisnUm:3djt;>ted Gsrnatv3wa;et'"able tir;hrBu';iem of i.rachir. e•aciliip reN_
Private Watet Supply well 4rxd Leaehing F46cly Oram,walls<isr
an sits m widn'n 2€A 1w of klehtng fuilitp) Pecs
Up otwtilmd and 1.aching Facility{lf m)watiaa kl ,Xist-
within}pp T.tn of 7cachiag feciUryj ��� ..._..__ Epei.
Fruniz.Red by �/t�t !t�'(sr+ O '
3
A/ t$ t
ZL
t5ins-11/10 Title 6 Official Inspection Form:Subsurface SewageDisposal System•Page 15 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane (aka#22 Finger Lane)
Property Address
Leon & Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town 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: 15 feet
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:
TopoObtained records for the site and surrounding properties.
❑ Checked with local excavators, installers -(attach documentation)
® Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Inspector has performed soil evaluations in this area and is familiar with groundwater depths.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface SewageDisposal System•Page 16 of 17
i ,
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 60-80 Finger Lane (aka#22 Finger Lane)
Property Address
Leon & Shirley Jaffe
Owner's Name
Osterville MA 02536 4/27/18
City/Town State Zip Code Date of Inspection
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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•11/10 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 17 of 17
s
RECEIVEi;
TO: Thomas McKean DATE: August 20, 2002
Public Health Department
Town of Barnstable
FROM: Paul Lebel
u / Y
SUBJECT: 80 Finger Lane—Citation 7/16/02
The following is a status report of the items outlined in your letter dated 7/16/02.
Renovation work was in process on units 60 and 80 Finger Lane at the time of your
inspection. This work included work on: floors,tile, windows and painting..
I received the notice on Sunday, July 20, 2002 and met with you on Monday, July 21,
2002. At this time the major infractions were already corrected. The remainder of the
items were corrected by Wednesday, July 23, 2002 except for the screens and signs. I held
off this report waiting for the screen (thP erg- Fder-btit-not yet in-hand.
X'q"I;o-;a I` .
Status: ' "
105 CMR 410.750K -; Completed'
105 CMR 410.750 (0) (3) - Complete
105 CMR 410.600 - Dumpster removed, area clean
Note the trash belonged to the complainant
105 CMR 410.553 - Complete
105 CMR 410.351 - Complete
105 CMR 410.504(B) - Complete prior to notice
105 CMR 410.481 - Posted
My contractor SteveNutter will install the kitchen screen as soon as he receives them. 80
Finger Lane will be vacant during October and November of this year.-
I will be out of state during,September and October. Please direct correspondence to:
P.O. Box 128
Marstons Mills, MA 02648.
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* COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS y
DEPARTMENT OF ENVIRONMENTAL PRO7ECTONE'VE®
.00T 2 4 2002
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 60180 Finger Lane �o
Osterville, MA 02655
Owner's Name: Paul Lebel
Owner's Address: Same
Date of Inspection: September 20, 2002
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map: 141
Osterville, MA,02655-0049 Parcel: 048
Telephone Number: (508) 862-9400
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-,
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date:. September 23, 2002
The system inspector shall su t 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
****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 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 60180 Finger Lane
Osterville, MA
Owner: Paul Lebel
Date of Inspection: September 20, 2002
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:
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 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 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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 60180 Finger Lane
Osterville, MA
Owner: Paul Lebel
Date of Inspection: September 20, 2002
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
x
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�tlie 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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
r
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
-CERTIFICATION (continued)
Property Address: 60180 Finger Lane
Osterville, AM
Owner: Paul Lebel
Date of Inspection: September 20, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either`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
T cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
T ✓ 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 coliform bacteria and volatile or 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 1.5.303,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 System:
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
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 E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 60180 Finger Lane
Osterville, AM
Owner: Paul Lebel
Date of Inspection: September 20, 2002
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:
Yes No
✓ _ 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(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: 60180 Finger Lane
Osterville, MA
Owner: Paul Lebel
Date of Inspection: September 20, 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
Does 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): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2001 - 117,000 gals.; 2000- 130,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALIMUSTRIAL
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: None on file-per treatment plant
Was system pumped as part of the inspection (yes or no): A'o
If yes, volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box, soil bsorption 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Nov. 13195-per as built card
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: 60180 Finger Lane
Osterville, AM
Owner: Paul Lebel
Date of Inspection: September 20, 2002
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx. 6"
Material of construction: ✓ concrete _metal _fiberglass Polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach-a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: - 9"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.): '
Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping
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
r
Page 8 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 60180 Finger Lane
Osterville, AM
Owner: Paul Lebel
Date of Inspection: September 20, 2002
TIGHT or HOLDING TANK: None (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: gallon_s/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
i
DISTRIBUTION BOX: ✓ -(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. There were no signs of solids.
PUMP CHAMBER: None (locate on site plan)
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.): '
F
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: 60180 Finger Lane
Osterville, AM
Owner: Paul Lebel
Date of Inspection: September 20, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits, number: 21o. profile- 1000 gal.
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.):
One pit(#4)had approximately 5"of water. The scum line was at the same level. The cover was approximately 6"below grade.
The other pit(0)had approximately 10"of water. The scum line was at the same level. There were no signs of failure. The
cover was approximately 10"below grade. The bottom to grade was approximately 7'.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (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
Page 10 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 60180 Finger Lane
Osterville, M4
Owner: Paul Lebel
Date of Inspection: September 20, 2002
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties tout least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where'public water supply enters the building.
Iil
cam.,
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FronT
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10
f Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 60/80 Finger Lane
Osterville, MA
Owner: Paul Lebel
Date of Inspection: September 20, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20' +/- feet
Please indicate (check) all methods used to determine the 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: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the leach pit to grade was approximately 7. Using the Barnstable topographic map and the Cape Cod
Commission water contours map, the maps were showing approximately 20'+%to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in_the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
V�
;> TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: 1n o y P04161'r/Its 11r e , Mail To:
BUSINESS LOCATION: '1 o -7 /b, b4l/y S'7— O57—. Board of Health
Town of Barnstable
MAILING ADDRESS: P.O. Box 534
TELEPHONE NUMBER: 61:2 6 2' Hyannis, MA 02601
CONTACT PERSON: anlm6a
EMERGENCY CONTACT TELEPHONE NUMBER: 4/1 L 2- 0 1
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES �O
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
q a Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
,40q;4 Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) - _ Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business
F
.� TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: A AigJyI p N PALY-rilva- / A C< �Mail To:
BUSINESS LOCATION: r7 @ `7 /2 A I A( �'`'T i "7— � /f Board of Health
Town of Barnstable
MAILING ADDRESS: 6 6-6-- P.O. Box 534
TELEPHONE NUMBER: Ldl 61 Hyannis, MA 02601.
CONTACT PERSON: (96 bQ d- -f—,4 6 lYl
EMERGENCY CONTACT TELEPHONE NUMBER: o�
c+
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES 'L<,_ NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS: '7 0 3 IV N d�` '�
TELEPHONE: fta y &7 C- a
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
t(6 Antifreeze (for gasoline or coolant systems) Drain cleaners
NO Automatic transmission fluid Toilet cleaners
N� Engine and radiator flushes _A Cesspool cleaners
8 Hydraulic fluid (including brake fluid) Ida Disinfectants
N 0 Motor oils/waste oils D Road Salt (Halite)
C Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oiler Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
0 Degreasers for engines and metal _ Photochemicals (fixers and developers)
Degreasers for driveways & garages I`t® Printing ink
Battery acid (electrolyte) I'NkO Wood preservatives (creosote)
6 Rustproofers 4R 0 Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
�\ Asphalt & roofing tar Leather dyes
�1,5 Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
S7 Paint & lacquer thinners PCB's
Gs Paint & varnish removers, deglossers _ Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
_ Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
M b Other cleaning solvents
a Bug and tar removers
to Household cleansers, oven cleaners
White Copy-Health Department/ Canary Copy-Business
'V 4
:TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
O unsatisfactory- 4.Manufacturers
COMPANY A10 M6.V &t/j/ (see"Orders") 5.Retail Stores
6.Fuel Suppliers
�ADDRESS Q Class: 7.Miscellaneous
MA QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
JOR MATERIALSUndergroundove
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel (A)
*NIP*], Kerosene, }
Heavy Oils:
waste motor oil (C)
Synthetic Organics:
degreasers
)5at�: '
m1 ��
Aw-
DISPOSAURECLAMATION REMARKS:
1. Sanitary Sewage 2. Water Supply r2
O Town Sewer XP Public
AOn-site OPrivate
3. Indoor Floor Drains YES NO
O Holding tank:MDC
0 Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES NO ORDERS:
0 Holding tank:MDC
O Catch basin/Dry well
O On-site system
5. Waste Transporter
Name of Hauler Destination Waste Product
�� YES NO
2.
K2 666_A-�-�
Person (s) Interviewed Inspector Date
M 1-; -
M UNITED STATES POSTAL SERVIC c�c
First-Class MaiF--'"
ID k1l Postage&Fees Paid
USPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
Board of HUM
Town Of Ban*ft
200 Main St
Hyannis,Massadws ft M1
i
w i
SENDER: SECTION. DELIVERY
■ Complete items 1,2,and 3.Also Complete !A. Received by(Please Print Clearly) B. Date of Delivery
item 4 if Restricted Delivery is desired. V
■ Print your name and address on the reverse
so that we can return the card to you. C:Signature
■ Attach this card to the back of the mailpiece, X ❑Agent
or on the front if space permits. ❑Addressee
D. Is delivery addr differenf fro i m 1? ❑Yes
1. Article Addressed to:
If YES,enter delivery address below: El
,4v-. Pa-K( ��I
P.O. &x az
Pta'rSf WS � e i
r��m 3. Sce Type
02 to�B LrJ Certified Mail El xpress Mail
❑ Registered — yr 2�rc!handise
❑ Insured Mail ❑ C.O.D.
C)C>C:> 1(0,7() 00r3 $ 0,7y( 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(transfer from service label)
PS Form 3811, March 2001 ` °'Domestic Return Receipt 102595-01-M-1421
Health Complaints
22-Jul-02
Time: 1:00:00 PM Date: 7/15/02 Complaint Number: 3533
Referred To: SAM WHITE Taken By: SAM WHITE
Complaint Type: CHAPTER II HOUSING
Article X Detail: UNSANITARY CONDITIONS
Business Name:
Number: 80 Street: Finger Lane
Village: HYANNIS Assessors Map Parcel:
Complaint Description: Complaint of mold, falling tile, leaks, etc. not
being fixed by landlord. has
lived there for 11 years and the landlord never
has anything fixed.
Actions Taken/Results: LM and SW met with at her
apartment in Osterville. Obvious damage to
bathtub tiles. Water leakage into cellar,
dangerously surrounding furnace with water.
No lightswitch panel near back door. Missing
door handle on closet door near front of
apartment. Pictures were taken and are on
file. Notice sent to Paul Lebel, owner, ordering
the repair to the tub, lightswitch, and door
handle.
Investigation Date: 7/15/02 Investigation Time: 3:00:00 PM
1
Town of Barnstable
Regulatory. Services
Thomas F. Geiler, Director
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
July 16, 2002
Mr. Paul Lebel
P.O. Box 128
Marstons Mills, MA 02648
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00 STATE SANITARY
CODE H-MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
The property owned by you located at 80 Finger Lane, Osterville was inspected on July
15, 2002 by Lee McConnell, RS, Town of Barnstable Health Inspector, and Sam White,
Town of Barnstable Health Inspector,because of a complaint.
The following violations of 105 CMR 410.00 State Sanitary Code 11 - Minimum
Standards of Fitness for Human Habitation were observed at 80 Finger Lane:
REGULATION 105 CMR 410.750(K): Water leaking from upstairs tub to cellar,
surrounding furnace. The tenant states the leaking water causes the furnace to shut off,
therefore requiring the pilot to be re-lit possibly endangering the safety of the tenants.
REGULATION 105 CMR 410.750(0)(3): No face plate provided at light switches (by
back door).
REGULATION 105 CMR 410.600: Uncovered roll-off, trash observed on ground.
REGULATION 105 CMR 410.553: No screens provided on windows in kitchen:
REGULATION 105 CMR 410.351: Missing closet door handle(by front door).
REGULATION 105 CMR 410.504(B): Missing tiles in shower. .
REGULATION 105 CMR 410.481: Owner's name, address, and phone number not
posted on site.
You are directed to correct the violations of Regulations 410.750(K), 410.750(0)(3), and
410.600 within 24 hours of receipt of this letter by providing a face plate cover over the
light switches, by repairing the leaking tub, and by removing trash from the ground and
covering the refuse container.
I
You are also directed to correct the remaining violations listed within ten (10) days of
receipt of this letter.
You may request a hearing before the Board of Health if written petition requesting same
is received within seven (7) days after the date the order is served.
Non-compliance could result in a fine of up to $500.00. Each days failure to comply
with an order shall constitute a separate violation.
PER ORDER THE BOARD OF HEALTH
T omas A. McKean,R.S.
Director of Public Health
Town of Barnstable
cc: Patty/Mary Ambrose
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FoRM30 Caw HOBBS&WARREN'M THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY/TOW N
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o DEPARTMENT
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ADDRESS
G9M
TELEPHONE
Address 0 Frt.g�_e-r Lane_a4eryt l__occupant �M _ Arose-
Floor Apartment No.._9 _ No. of Occupants
No.of Habitable Rooms 3 No.Sleeping Rooms
No. dwelling or rooming units c��c2� No.Stories___
Name and address of owner_S�k_1 { � P•6 • i z? Ho-, a►.,s mls /q.* ou q$
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish aneoV Qv rall-o Vi-Qs{h eel r0",1W WA)
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M oors indows: MISSIAR yo.553
Roof ;. `' o c t alaor k_ 10 C y/D.35I
Gutters, Drains:
Walls.-
Foundation:
Chimney:
BASEMENT Gen. Sanitation:
Dampness: A" o .4 ;rs f 4lb /OSC y/Yl.M(k
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.: }
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS - ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.: Ex osg 1 1&0 no fece fa4e* Atae back d r 10370 �C 1//0•966(013)
❑ 110 ❑ 220 Fusing,Grnd.: (,` sw&.
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect..-
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin, Shower or Tub: n„Ssin 4.'k s s�ow�!r /USCi 1k yio.3o`/�Q�
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Buil ing Posted O%dAer'i i�Amx akUress 9l6.19 Aulyl}3ee na-h nos
Locks on Doors: pn s; e.
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 0 UPI
00
INSPECTOR TITLE
A.M.
DATE 4"' '7 0 15 2- TIME Jam-3D _ �P
A.M.
THE NEXT SCHEDULED REINSPECTION S Ile" P.M.
i
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shali be deemed conditions which may endanger or
impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has.the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including-garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
OF/BARNSTABLE
Wt;,,, TION � �COWN
� t/ lA/UL- SEWAGE #
YVII,LAGE OST�w� I ASSESSOR'S MAP*& LOT lY
"',;}INSTALLER'S NAME&PHONE NO. /4-1" o 4A.-0Q 1
p; ,,SEPTIC TANK CAPACITY
BLEACHING FACILITY: (type) /fir l Pi I(size)
NO. OF BEDROOMS I
BUILDER OR OWNERC-I �.e- e.J
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by Ib.� O/
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Z?i TOWN OF BARNSTABLE
LOCATION c � IANE SEWAGE # 1-> �� J
'4tLLAGE (� Y��j V/�/ ASSESSOR'S MAP & LOT /�/- 18
INSTALLER'S NAME & PHONE NO. Sum,2ar
SEPTIC TANK CAPACITY /,So r A
0, R6
LEACHING FACILITY:(tyle) I A ��� (size)
NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER ? Ui// C
BUILDER OR OWNER � � �Rlr
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Mupuual World, Tomstrur#ion amit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
4.
..............................................................
Location
1IL./ ex ? dress- or Lot No.
-------- s t
owner Address
---•-----------------------'---••----•----..._•••--
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No, of Bedrooms-----------f----------------- - -----Expansion Attic W) Garbage Grinder W)
114 Other—Type of Building No. of persons---------------------------- Showers — Cafeteria
Q' Other W fixtures
Design Flow................S� __._. __
_ =.--.._._._.._.__..gallons
per person per day. Total daily flow........lffQ.......................gallons.
WSeptic Tank—Liquid capacityA:$OQ-gallons Length---------------- Width---------------- Diameter---............. Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No/*4'. ._.. Diameter.....1..Q--------- Depth below inlet-----4;........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) � �;rg
�' Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil_.,�y4_�l__'. Gl_-_--} -------------------
x
U •--•------------------------------------'------------------------------------------------•--•'---...-----------------------------------------...--------------------------•----'._.....--------•-
x --- ..................................
o
U N ture f R airs or Alterations—Answer when applicable'/vC �r�lL_.. �?l�C__-___f:/+��W_____.
f��p�-= 929442..
5-----------------------------------------------------
Agreement. A- f`o �®
The undersigned agrees to install the aforedescribed In ivi�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 Compliance has bern} rd,4y th oard of health.o
.
Signed . ..... .......... . .......... .......----- - - -------------
�7. ..l... ....
Application,Approved B �n ----------- ---- e
PP PP Y "` -:1re
Application Disapproved for the following reasons- -------------------- -------- -------------------------------------------- -----------------------------------------------------
----------------------------------------------------------.........--------....----...._....._. ..- ---------------------
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Permit No. 9 `.-----./..�................ Issued ........V. v......7- -- Dale- ...
Dare
v THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Dit oiittl Workii Tomitrur#inn Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
• o /i�'C��2 .ir. ........................................... Goff-G ��.� - /¢/ st ..................................y
Location- , dress dress or Lct No.
r€ rrL__�'.�r- G z�s�ibis�iC. 19e /his .�/s Mid CJZ s�
- ----- s
Owner Address
a 1 � Tom- = ----................................................ ��-103aX«....--%rstis._ %ems Gz
Installer Address
UType of Building Size Lot.................... q. feet
Dwelling— No. of Bedrooms...........�---------------------- -----Expansion Attic W) Garbage Grinder W)
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures ----•-----••-•----------------------------------••--- ---------•---....-----------------•---..-•--•---.-----------.
W Design Flow..--------------------
.._........__--gallons per person per day. Total daily flow--------¢¢0........................gallons.
WSeptic Tank—Liquid capacitv�S,qU-.gallons Length-----------_-- Width---------------- Diameter-_-..-.-------- Depth................
x Disposal Trench—No- -------------------- Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit Nod NL-K/ Z--.. .-.-- ®---- Depth below inlet................ Total leaching area..................sq. ft.
Other Distribution box ( ) Dosing tank ( ) 15 78
Z .- Percolation Test Results Performed by-------------------------------------------------------------------------- Date.........................__....--•.•-
Test Pit No. I................minutes per inch Depth of Test Pit---.--------_.----_ Depth to ground water.-..-.-..----------.-.-.
44 Test Pit No. 2................minutes per inch Depth of Test Pit------------------.. Depth to ground water........................
�+ ---
O Description of Soil.. 51..... /i✓c/�----------------------
V ....•----•----•••-•.....-•••••••--•---•-••-••••-•-•••--•-•••---•-•-••••----•-•----•••••••••••---••----••--••---••------------------••...•------••--•••-••-----••••••-•-•--•••--•.....---•-••----•-••-••.
W
-------------------------------------------------------------------------------------------------------------------------------------
U Nature of Rye airs or Alterations—Answer when applicable-1 C!-v. v0-- [_-. ------c_.-... _'% E
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 Compliance hasbeen ed by the board of health.
Signed .................. .. . ... ----------- - ...... ---V47.h
/Da
Application,Approved B -- ------------------------------------
Application 1P /7�
PP PP Y -- ...
Dace -
Disapproved for the following reasons- -------------------------------------------------- ----------------------------------------------------------------------------------
.............................. .. . ...................._-------------------- --------------------------------------------------------
Dace
Permit No. /.. :.----- /- T- ........... Issued ..........��.-•�� ���-
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH j
TOWN OF BARNSTABLE
(fPr#ifiratr of C ontylinurr
THIrIS-TO CERTIP ,That the Individual Sewage Disposal System constructed ( ) or Repaired )
by
�� �Z ,� �JJ Ll
� - -e` er.----- --...� ---------- -f--�------- ` f�------- - --- ------- ¢l�
at �Df �L - -----------------------------------------------------------
has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. , - `.�..Z..f ------------- dated ...--3/,-)
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM VYILL FUNCTION SATISFACTORY.
DATE.. ._ .... .. Inspector>.'-' . ......�.... _.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
gam, TOWN OF BARNSTABLE �� 0
No....... . •. FEE................. .
.......
Rio nsttl - orko nno#rnr#ion lerntit
Permission is hereby granted------------ ( ----•••---._z..&*-_- ----------------------------------------------------------------••--------.-.-.---
to Construct ( ) or Repair (i--) an Individual Sewage Disposal y tem
at .`L!1.--��..------�51�vtLLL---..�..�.--.... ¢'��tem
at " 1 I�-7)
as shown on the application for Disposal Works Construction Permit No.---_-----..---_-_.- Dated.....__3_..............................
_ ....... —� BO5 d OF I ealt raj
DATE................ ---�-�--=•-�-� .------------------ -
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