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HomeMy WebLinkAbout0018 BLUENOSE LANE - Health 18.Bluenose Vane Marstons Mills A= 121 — 144 - 008 i -Y TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Z® 7,0 Z`- Time: In Out Owner )0 1J (_'7 LA_P,R 3�> Tenant J L{yy)A 1A Address ]&-Lk( 1V0� �/�NL Address 7-t l ,Ny1r;7 Compliance Remarks or Regulation # Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities47Cz—:fq[ . t 4. Water Supply ✓ 5. Hot Water Facilities ® 10 A (a s VW 6. Heating Facilities ®r IA)see��Covllj 7. Lighting and Electrical Facilities 8. Ventilation J 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural j Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed Nib PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms 3 Number of Vehic ow max) Number of Persons Allowed (max) Person(s) Interviewed u onA ?- Inspecto If Public Building such as Store or Hotel/Motel specify here r 114 TOWN OF BARNSTABLE Approved: -ZG eiq _ BOARD OF HEALTH MLD Cert: - ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 6 'Z 6- Z 0or-t Time: In /.'(�� Out Owner c3 ti tJ L V N`tea Tenant c> ► ME, 9— 1Z_T jT k .. Address n^1 s 12�! � ice. tZ-Q Address 8C,u,.NO Sz (-A" E J'�i as N �Av'�'►.1 �'ter oz I c�1 ©s?. 1 Y1�,�S1otis ,�I�Lc.S J��L4 ��GSS Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities � H 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities -� •v 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal ►C,� 16. Sewage Disposal ✓ '� �� 17.Temporary Housing ps 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; ���- Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (may Person(s) Interviewed Inspector - s If Public Building such as Store or Hotel/Motel specify here � ° FORM30 ��W HOBBS&WARREN TM THE COMMONWEALTH.OFMASSACHUSETTS BOARD OF HEALTH CIT /TOWN W IN a DEPARTMENT ADDRESS M s"y`0 / T LEPHO Address 0 �I VE !I�t� _ & Occupant_ Floor ApartmeKit No. No. of Occupants No.of Habitable Rooms No.Sleeping Rooms_ No.dwelling or rooming units_ No.Stories Name and address of owner Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: 01110 Dampness: f Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: Aj HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair (i/ TYPE: Stacks, Flues,Vents: VV PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: e H.W.Tank(s)Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 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: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTIO REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIE OF UFiY." INSPECTOR �' �` TITLE A.M. DATE log TIME �u6 A.M. v THE NEXT SCHEDULED REINSPECTION z(. P.M. r 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply 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. \ �� LO� � Parcel Detail Page 1 of 3 / 4 �7 fi a s, Sr i 19 - 2 - f.niA A��':_ .,..., _ _ % G-'G' i !'4=yr•'L .,{r 2 Logged In As: Parcel Detail Friday, Mi Parcel Lookup Parcellnfo Parcel ID 121-144-008 Developer Lot LOT 46 - __ — — ------ - ----- ------ Location 18 BLUENOSE LANE Pri Frontage 132 Sec Road Sec --- Frontage _ - ---- ---- Village MARSTONS MILLS Fire District;C-O-MM Sewer Acct Road Index ;0142 Interactive a Map �'I `)g 5 T Owner Info Owner GUARD, JOHN R & EILEEN J I Co-Owner Streets 7765 GREENBRIER RD Street2 City PENNSAUKEN State NJ- zip 08109 Country Land Info Acres 0.49 use Single Fam MDL-01 zoning RF Nghbd 0108 Topography Level Road Paved utilities Public Water,Gas,Septic Location Construction Info Building 1 of 1 Year Roof — Ext Built Struct Wall 1989 1 Gable/Hip Wood Shingle _ - — _. --- — .-- Effect I Roof AC Area 1898 — Cover Asph/F GIs/Cm Type None - _-_ Style Cape Cod _ wan nt Drywall Rooms Be 3 Bedrooms Model Residential Int - -- Bath 2 Full �I - Floor - Rooms 2 Grade'Average Grade Type Hot Air � Total 6—Rooms — — - Rooms - - --__--- - http://issql/intranet/propdata/ParcelDetail.aspx?ID=7627 5/18/2007 Parcel Detail Page 2 of 3 Heat Found- FEP GAS. Stories 1 1/2 Stories { Gas 1 Poured Conc. 7'•4 aMi Fuel --- ----_____ ation 12: Permit History Issue Date Purpose Permit# Amount Insp Date Comm 10/29/2003 New Addition 72637 $6,000 2/26/2004 12:00:00 AM FIREP 7/12/2001 New Addition 54485 $10,000 11/13/2001 12:00:00 AM 12/1/1989 B33414 $45,000 1/15/1991 12:00:00 AM OS 11) - Visit History Date Who Purpose 1/4/2007 12:00:00 AM Paul Talbot Cyclical Inspection 2/26/2004 12:00:00 AM Martin Flynn Mea./List Bldg Permit Only 11/13/2001 12:00:00 AM Martin Flynn Mea./List Bldg Permit Only 11/16/1998 12:00:00 AM Donna Dacey Mea + Corrected Listing 1/15/1991 12:00:00 AM ML Sales History Line Sale Date Owner Book/Page Sale P 1 10/25/2006 GUARD, JOHN R& EILEEN J C181434 2 8/1/2006 DOWICK, CHARLES C180756 3 10/2/2000 VAN GERVEN, NICHOLE C159265 4 3/15/1990 CALLINAN, DANIEL J &CAROL C120149 5 10/15/1989 DACEY, WILLIAM E III TRS C118877 6 4/15/1985 ARCHIBALD, THOMAS C101009 7 ARCHIBALD, WILLIAM C71580 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parc( 1 2007 $174,300 $2,800 $600 $229,800 2 2006 $151,700 $2,800 $700 $217,200 3 2005 $142,300 $2,800 $700 $144,800 4 2004 $113,500 $0 $700 $123,000 5 2003 $103,500 $0 $700 $48,500 http://issql/intranet/propdata/ParcelDetail.aspx?ID=7627 5/18/2007 Parcel Detail Page 3 of 3 6 2002 $99,300 $0 $0 $48,500 7 2001 $99,300 $0 $0 $48,500 8 2000 $79,500 $0 $0 $30,000 9 1999 $79,500 $0 $0 $30,000 10 1998 $79,500 $0 $0 $30,000 11 1997 $78,600 $0 $0 $22,500 12 1996 $78,600 $0 $0 $22,500 13 1995 $78,600 $0 $0 $22,500 14 1994 $80,200 $0 $0 $27,000 15 1993 $80,200 $0 $0 $27,000 16 1992 $91,500 $0 $0 $30,000 17 1991 $41,100 $0 $0 $48,700 18 1990 $0 $0 $0 $48,700 19 1989 $0 $0 $0 $48,700 20 1988 $0 $0 $0 $17,900 21 1987 $0 $0 $0 $17,900 22 1986 $0 $0 $0 $17,900 Photos F' LAI •� # ". iii f r � http://issql/intranet/propdata/ParcelDetail.aspx?ID=7627 5/18/2007 FORM30 &w Hoim&WARREN'" THE COMMONWEALTH OF MASSACHUSETTS BOA, D OF EALTH CITY/TOWN r a DEPARTMENT, cgm 1'Wv(I 4 DRESS WM s°y`e s LEP ONE Address Ue�c�se,C�Cyt�2 Occupant Floor Apartment No. No.of Occupants No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units No.Stories Cr /o Name and address of owner Cwyr-LV YP _ ICl1� __A ,. UGp Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows.: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Su ply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd..: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 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: Infestation Rats, Mice, Roaches or Other:- Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS IN ECTIO EPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI I FMRY.' 11 '1 INSPECTOR TITLE A01k . DATE TIME !�� P- A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply 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. FORM-30 &W HoBRs&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BO _ - D OF EALTH f CITY/TOWN W �V a DEPARTMENT, ! o 'p p DRESS GM V _ � TELEP ONE Address 16?)0eQoe e LQ )-P_ — Occupan Floor Apartment No. No. of Occupants No. of Habitable Rooms No.Sleeping Rooms No. dwelling or rooming units No.Stories___,,,,,,,_ p , l}� Name and address of owner 1 X�IYr,� . _�l� !C!✓ �[(J�P/(� ^��r Remarks Reg. Vio. 6616 7,�� YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: 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.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom.4 Hot Water Facil. Su .'Ten.-rGas,QiI, Elect:: = t Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION-REPORT. IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIW OF PERJU Y." t INSPECTOR TITLE DATE_, _ TIME P.MI. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises,shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply 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. TM " THE COMMONWEALTH OF MASSACHUSETTS FORM 30 C&W HOBBS&WARREN F .� 1 BO D OF HEALTH CITY/TOW N J w DEPARTMENT a H1 i RESS D �A. Sey`0 J�Q, TELEPHONE Address�??JueQ ,—P +�-o ue --Occupant Floor Apartment No. No.of Occupants No. of Habitable Rooms No.Sleeping Rooms No. dwelling or rooming units No.Stories Name and address of owner �'1 ti` '� �TYoP r JCS✓ I>�I�R)yJV �iI�,+� Remarks Reg. Vio. YARD Out Bld s.: Fences: Garba e and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. '.Sup.'Ten.-,-,Gas,Qil, Elect.; Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: A General Buildina Posted ) Locks on Doors: j ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION-REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJU'Ft#Y." n J INSPECTOR i/� TITLEf" ?/ DATE t TIME 0 Q P.M,> ' A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply 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. CC/V� &W HOBBS&WARREN Tan THE COMMONWEALTH OF MASSACHUSETTS FORM 30 C BOAtd\t�l OF HEALTH CITY/TOWN W b DE ARTMENT etas. 'q r AePRESS n — I( � (t� �( t T PHONE Address I 'fie(�C) _ O." Floor Apartment No. No.of Occup is No. of Habitable Rooms No.Sleeping Rooms No. dwelling or rooming units No.Stori s Name and address of owner zy(_ �ocxy , p Q3Tx13 &t Osao Remarks Reg. Vip o �� q YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls.- Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Z Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink OXF Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INRPECT)ft REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI P ' INSPECTOR TITLE- �� DATE © TIME Ip A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply 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. f &w HOBBS&WARRENIM THE COMMONWEALTH OF MASSACHUSETTS FORM 30 C BOA D OF HEALTH CITY/TOWN` DE ARTMENT AlJ DRESS Q �M # f� ` TELEPHONE tom Address 1 �J "4_ --Occupant Floor Apartment No. No.of Occup its No.No.of Habitable Rooms—_ No.Sleeping Rooms No.dwelling or rooming units No.Stories ♦ `' Name and address of owner oC4, d () PA.) ►V3 YARD Out Bld s.: Fences: ' Remarks Reg. VioY.,/ �9 1 Garbage and Rubbish ' Containers: Drainage Infestation Rats or other: _ 0 1./f STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: { "> Chimney: BASEMENT Gen.Sanitation: -t Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: 1 :. HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 144-44 E' Bedroom 4 Hot Water Facil. SUF.Ten., Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove` Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: p General Building Posted °'1 0r Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PER)URY.�' �t INSPECTOR f� jl I 1 �oal TITLE .d / v M. DATE i 3 "T TIME /0 A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply 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. j "'TOWN OF�-�1BA�RNSTABLE LOCATION /✓t n�o.S P - ` 1 b1� Y' SEWAGE AMP VILLAGE 6' Szz 4 ;riiZ,, ASSESSOR'S MAP & LOT & — ~� INSTALLER'S NAME&PHONE NO. /YI SEPTIC TANK CAPACITY /sa U LEACHING FACILITY: (type) L,t /apt�' (size) NO. OF BEDROOMS S2 v BUILDER OR OWNS 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 T7t�� I � rM Lai �r No. C-J;0V —_S-7 Z" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppricattou for DigV�IITT_ at 6petem� Construction Permit Application for a Permit to Construct( )Repair( grade( )Abandon( ) O Complete System >4 Individual Components Location Address or Lot o. vr,1l(6.5f--_c Lln^_rz_ Owner's Name,Address and Tel.No. \ Assessor's Map/Parcel6`S 2u11`e i D-1—I�"S QI9'I I N a Installer's Name,Address,and Tel.No.' Designer's Name,Address and Tel.No. MM ID-� Type of Building: Dwelling No.of Bedrooms Y2 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3'-�G1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 5F-r,zc Vfs w� L6w E)P, p«- Type of S.A.S. Cc, < Description of Soil 4,t-=q -'sou . Nature of Repairs or Alterations(Answer when applicable) _ ta-Sl�1\ Y`yec,-,j L)-aCY 9r(_6 mac, �e.L r THE 'I KI z;c L i y-,--u at � tA �,kk -ST4-2.__ Q,A, ! - - t w t UK Fti et,3Z-1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enyir rimental Code an to place the system in operation until a Certifi- cate of Compliance has of Health. Signed Date 9oel1-� Application Approved by Date �'-�7-?rdyw Application Disapproved for the following reasons Permit No. Date Issued No.� dt Fee THE COMMONWEALTH OF MASSACHUSETTS ' ' Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZppYication for Oizpo aY *pmem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System Individual Components Location Address or Lot o. I/C��l(65F e `� I4�'t Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. e,^ Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms _. Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow "�,' l7 gallons per day. Calculated daily flow 3"-kGi gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank !2.cn crx Ono o Type of S.A.S. 4, �c g "cj c, Description of Soil Nature of Repairs or Alterations(Answer when applicable) LL QL frr c.1 v m..-A t t Ut S7Vcv-e— 011 A C.i lls ;r -F (t-(t'OvlQ A_e� L Date last inspected: Agreement: g The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of.Title 5 of,,the Environmental Code an to place the system in operation until a Certifi- cate of Compliance has n-issue'd-by�e"his-B' � of Health. Signed Date Q mm) Application Approved by Date 9$-Z 7- Application Disapproved for the following reasons Permit No. Date Issued ------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( ) w at LA, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No-Teg /-L IZ.- dated 9-Z 7 74iW. Installer Designer A Al Z The issuance ofmt sJ�e t _hall not be construed as a guarantee that the s Ke w' 1 � � ' n s d1si nedl Date Inspector o '� 0 --------------------------------------- No. -W — S Z T Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpo_qai *pgtem 9n4tructio n Permit Permission is hereby granted to�o struct( Repair Upgrade( )Abandon( ) System located at / ��s 3�n(�./ LAU and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. , Date: f Approved by J . : 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. e CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, , hereby certify that the application for disposal works construction permit signed by me dated g-27-6V , concerning the property located at d/-� /UD,S /N f QS/ meets all of the following criteria: `�- This failed system is connected to a residential dwelling only. There are no commercial or business "Ses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system • /Fhere are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed There are no variances requested or needed. /• The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen (14)feet above the maximum adjusted groundwater table elevation, Please complete the following: �� A) Top of Ground Surface Elevation(using GIS information) ,� / 1 B) G.W. Elevation �a0 +the MAX. High G.W. Adjustment. /t 8 = 1 DIFFERENCE BETWEEN A and B �j 5 SIGNED : DATE: [Please Sketch propose plan of syste on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert - -------- - ----------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired( )Upgraded(i--r Abandoned( ) b S at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.—VOZ z(-S"12--dated 9—Z —2-ez-W Installer Designer ` The issuance of s e s all not be construed as a guarantee[hat the sy m c i n d e q i Date Inspector - a Mid-Cape Septic 15 Louis Street Hyannis,MA 02601 (508)778-0684 Name Le Date M Quantity Description Cost E 6 C s � - i Tot JdG%� MICHA .DUNNING,CONVEYANCE&ESCROW ACCOUNT 8 5 0 2 DUNNING&KIRRANE,L.L.P. Check Number: 8502 Check Date: 10/2/2000 Payee: Mid Cape Septi,c,Co. Payment Amount: $3,300.00 Memo: 9105.000 Cash Nicole Van Gerven 18 Bluenose Way, Osterville, MA 02655 f MICHAEL A.DUNNING,CONVEYANCE&ESCROW ACCOUNT 8 5 0 Check NumbeUNNMB KIRRANE,L.L.P. Check Date: 10/2/2000 Payee: Mid Cape Septic Co. Payment Amount: $3,300.00 Memo: 9105.000 Cash Nicole Van Gerven 18 Bluenose Way, Osterville, MA 02655 SF13103-1 TO REORDER,CALL YOUR LOCAL SAFEGUARD DISTRIBUTOR AT 800-346-7550 GBFBF10010000 LSSSF007654 Safeguard _ih0uS4 SFSLZ CK7S08112L l;391 ` Commonwealth of Massachusetts Fills 5'®ffociaP Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form CZ 4/</ Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General information 1 Property Information: 18 Bluenose Ln Osterville Property Address Nicole Von Gervyn T -owner's Name 18 Bluenose Ln Owner's Address �terlle t?,1 z-v MA 02655 ..Cityfrown State Zip Code Date of Inspection: Date 6 Date 2. Inspector. Shawn Mcetroy Name of Inspector n , S.M. Enterprises Company Name i 29 Atwater Dr Company Address L� E. Falmouth MA ?`02536 Cityrrown state -Zip Code 508-495-0905 Telephone 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 ❑ Pails ❑ N !Per Ev uation by Local Approving Authority 8-1-06 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 10,006 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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 wilt perform in the future under the same or different conditions of use. t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System NN Commonwealth of Massachusetts f Tift 5 Official Inspection Form r { Not for Voluntary Assessments - - Subsurface Sewage Disposal System Form B. Certification (cunt.) s. 18 Bluenose Ln - Property Address w= Ostervilfe MA 02655 City/Town State •'Zip Code Nicole Von Gervyn 7-31-06 Owner's Name Date of Inspection 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 in good condition with no signs of failure. 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 infitrationor exfikration 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. .,.. 7 ,, *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: t5insp.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts ` Fills 5 Official Inspe ' dog f®r Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 18 Bluenose Ln Property Address Osterville MA •02655 City/Town state Zip Code Nicole Von Gervyn 7-31-06 Owner's Name Date of Inspection 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 ❑ 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: 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 t5insp.doc.03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 4 Commonwealth of Massachusetts _ r - Official Inspection- Form Title Not for Voluntary Assessments Subsurface Sewage Disposal System Form- B. Certification (cont.) 18 Bluenose Ln Property Address Osterviffe MA . ,,02655 City/Town State 'r.Zip Code Nicole Von Gervyn 7-31-06 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health.(cont.):" r 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: ., k_ "w •e ❑ The system has a septic tank and soil absorption system,(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply.-- ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the.SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS.and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. ' Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 4 of 16 Commonwealth of Massachusetts Title 5 Official pnspecti®n Fdrm Not for Voluntary Assessments . Subsurface Sewage Disposal System Form M B. Certification (cont.) 18 Bluenose Ln Property Address tOsterville MA 02655 City/Town state ZipCode Nicole Von Gervyn 7-31-06 Owner's Name Date of Inspection : 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 F 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 ❑ ® Required pumping more than 4 times in the last year MOT due to clogged or obstructed pipe(s).Number oftimes 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 roust be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. Yes No ❑ 0 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. t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts - Title 5 Official lnspection-form l,. :_ ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form , :+ B. Certification (cost.) 18 Bluenose Ln Property Address : Ostervlffe MA 02655 Cityrrown State Zip Code Nicole Von Gervyn 7-31-06 } Owner's Name Date of Inspection 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 <4 ❑ ❑ the system is within 40D 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 shalt upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. - 4 t5insp.doc-03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form N C. Checklist 18 Bluenose Ln Property Address Osterville MA 02655 City/Town State Zip Code Nicole Von Gervyn 7-31-W Owner's Name Date of Inspection 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 NIA) ® ❑ 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)] t5insp.doc•03/2006 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection* Forte Not for Voluntary Assessments Subsurface Sewage Disposal System Form'. t M D. System Information 18 Bluenose Ln Property Address Ostervilfe MR , 02655 Cityrrown State Zip Code Nicole Von Gervyn 7-31-06 Owner's Name Date of Inspection Residential Flow Conditions: r `t Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[it yes separate inspec ion required} ❑ Yes ® No 4. Laundry system inspected? r ' ❑ Yes ® No Seasonal use? rTM ❑ Yes ® No Water meter readings, if available past 2 years usage(gpd)):,- Sump pump? ' ❑ Yes ® No Last date of occupancy: 7-31-06 Date " S ,A Commercial/Industrial Flow.Conditions: Type of Establishment:; s Design flow(based on,310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatsipersonslsq.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: Last date of occupancy/use: Date Other(describe): t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Valle 5 Official Inspection form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 18 Bluenose Ln Property Address Osterviffe MA 02655 City/Town State Zip Code Nicole Von Gervyn 7-31-06 Owner's Name Date of Inspection General Information Pumping Records: Source of information: none 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) (rf yes,attach previous inspection records, if any) ❑ Innovative/Altemative 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: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts TWe g Official Inspection.,'F&M*' Not for Voluntary Assessments Subsurface Sewage Disposal System Form'_: D. System Information (cont.) 18 Bluenose Ln " Property Address Osterville Ma 02655 City/Town State Zip Code Nicole Von Gervyn 7-31-06 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 'fe°t Material of construction: ❑ cast iron N 40 PVC ❑ other(explain): Distance from private water supply well or suction fine: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): rR «. , 14" Depth below grade: f _ 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 El Yes ❑ No certificate) t --- --& `,T ------------------------------------------------------------------- --------------------------------------------------- 1000 gal Dimensions: ,-. . .. - � • � . . - , � �;�� _ Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness = } < 0. . Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle , ,, 14" How were dimensions determined? tape t5insp.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts o aTle Unoclao 80-05P -tto For Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M D. System Information (cont.) 18 Bluenose Ln Property Address Osterviffe MA 02655 City/Town State Zip Code Nicole Von Gervyn 7-31-06 Owner's Name Date of Inspection 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 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)(tacate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): t5insp.doc-0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts • Title 5 Official Inspettoon Fdrm' . . :. Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) '•t 18 Bluenose Ln Property Address Osterviffe MA ;,: 02655 Cityrrown State Zip Code Nicole Von Gervyn 7-31-06 �P a Owner's Name Date of Inspection Tight or Holding Tank (cunt.) rr' 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 Distribution Box(if present must be opened) (locate on site plan): ; Depth of liquid level above outlet invert 0 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:): a , good condition. Pump Chamber(locate on site plan): Pumps in working order: Yes ❑ No Alarms in working order. ❑r Yes , ❑ No t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts > . Title 5 Official Inspection form Not for Voluntary Assessments Subsurface Sewage Disposal System101 Form M D. System Information (cont.) - 18 Bluenose Ln Property Address Ostervilfe MA 02655 Cityr town State Zip Code Nicole Von Gervyn 7 31-06 Owner's Name Date of Inspection 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: v Type: ❑ leaching pits number: ❑ leaching chambers number- 0 leaching galleries number. 4-infiftrators ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/arternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): I Vx25`field in good shape with no sign of failue. t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 13 of 16 Commonwealth of Massachusetts _ ,• : �b ; . F __ . Title 5 Official Inspe'ta®n :*Form,M .. Not for Voluntary Assessments Subsurface Sewage Disposal System Form-; D. System Information (cont.) -M.rw, 18 Bluenose Ln 3 Property Address Osterviffe MA s 02655 Cityrrown State Zip Code Nicole Von Gervyn 7-31-06 Owner's Name Date of Inspection , . 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. not, .11, Depth of scum layer i Dimensions of cesspool Materials of construction Indication of groundwater inflow Q Yes Q No Comments(note condition of soil,signs of hydraulic failure, level,of ponding,condition of vegetation, etc.): �,.� ,.�. Privy (locate on site plan): :t t{f�t;rz•a�;4 Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc-03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 14 of 16 'Commonwealth of Massachusetts { Tifle .. Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System information (cont.) 18 Bluenose Ln Property Address Ostetvtffe lid 02655 Citytrown State Zip Code Nicole Von Gervyn Nicole Von Gervyn Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters Yhe'mdAng. A - 1=- �I7` d- i- r t5insp.doc•0312006 Tittle 5 Official inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Toile 5 Official Inspection (dorm. Not for Voluntary Assessments - Subsurface Sewage Disposal System Form , D. System Information (cont.) 18 Bluenose Ln Property Address Osterviffe NIA 02655 Citylrown State Zip Code Nicole Von Gervyn 7-31-06 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: original design plans on record shows no groundwater at 17. t5insp.doc-03/2006 Tdle 5 Official Inspection form:Subsurface Sewage Disposal System- Page 16 of 16 TO � ARNSTAB �'`V C 4eCATION r (0e VL a5 SEWAGE # VLLLAGE C ��r '�' <<-P ASSESSOR'S MAP & LOTF7 ZII O AME&PHONE NO. Y)N )(2 SEPTIC TANK CAPACITY A20 0 P a LEACHING FACILITY: (type)` �(` r—fE WS� �TJ NO. OF BEDROOMS t. BUILDER OR OWNER 120LV`, tt PERMTTDATE: COMPLIANCE DATE: 0 00 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility A A Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of.leaching facility) V k Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r _ �� _ �* �c,t r� '�` J `t. �.�� g 0 5� � � �, �� , . �� 3 � �� �-��G TOWN OF BARNSTABLE LOCAnON f f 13I t e n b Se L PI SEWAGE # VILL•AE 05-�-ecr L) e ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /©O O LEACHING FACILrTY: (type) �y1• � f% n�-ef S (size) NO.OF BEDROOMS 3 f f BUILDER OR OWNER-t LO 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 --5`a4a Senhe--1 ohs p���.Uvt 57 t� o st � Q�D 36 p /-! "C- N Oe ARNSTABLE V LOCATION nla-AIO-ige hAe,SEWAGE # ILLAGE ASSESSOR'S MAP & LOT Z I 14 �� S NNSTALLER'S NAME & PHONE NO. jJ r J)ki560 /J ,,,SEPTIC TANK CAPACITY /� ! EACHING FACILITY:(type)i ���c� ' (size) rl J NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATE BUILDER OR OWNER P E. Q C0 4. DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �•® ' VARIANCE GRANTED: Yes No 4 t. i ,. No.- y FR$......1\..'2" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r0os.✓ ............ -----� -----.....OF----------------------------------------------------------------•------....._...__........ AVV irFation for Bhgpaii al Workii Tomitrurtion Vrrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ................_............................................................................... --........---.............----------•----------- ------------ .Locatiog-Address or Lot o. ..........:� ...... .. •.--�c� - --•-•---- �a� .a.----• ---------------------------------•-------. , .—nVer C Address Installer Address Type of Building Size Lot��j•._-�-G'--------Sq. feet �., Dwelling—No. of Bedrooms............................................Expansion Attic (,No) Garbage Grinder (A/) Pa., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtu es ................•......•-----. --------------••-------------•---------- g �.........................:gallons per person per day. Total daily flow___....._ gallons. W Desi n Flow_________________ .............................® WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( �) /- - ,//� `" Percolation Test Results Performed by._....._9ev' tC�____ '_... yy. _... Y �1_..__..__..e.___.. a a i-;---- ---- Date ...4 T est Pit No. 1..............:.minutes oer inch Depth of Test Pit-------._........... Depth to ground water_.`�4._�__._____- Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..-________-____--______ P+ ...-...... W -- t°� � Description of Soil-----------skE�1 U� =1'A� ..... �------....-•-•-•-----------------------------------•---------------------------------------- x ------ •---------------------------------------------------------------------------------------- V ..........................-•••••-•-•---------••••-••••--•---••••-••••-•••••--••--•---•••••-•-••--•-•----•-•-••-•----•---•-----•-------•-•••••---••------•------•-•---•••••....-------•--••-------•--•--- W ---•-••-------------------------•--•---------•--•------..-•---••----•-••---•--------••-------...••-----•--•-----•-•-•------....------......•-•-•-----------•---•-•-•-----......-•--••--._.............. U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ------------•-----•----••----••-----•------------•----------------•------•--------•------•--•-------•------•••----••..-----••--•-•......----•-----...••--•.-•-••••-•-••......-•...._..------------ Agreement: The undersigned agrees to install the aforedescribe Individual Sewage Disposal System in accordance with !`1T P1�-� LE the provisions of'TT LE5 of the State Sanitary od e undersigned further agrees not to place the system in operation until a Certificate of Comp_iance has ee s e the board health. Signed...... --- . --------------------- -----------•-----------------.---- �� moo .... D e ApplicationApproved BY E "s ^` ..-----••--•-•---••--•----•--------•- ........................................ Date Application Disapproved for the following reasons-----------------------------•---•-----------------------------•--------------------------------•------.....----- .......•--------•---•--••-••-----•-•-------•-•-....•-•••---•-•-----••-----------------•-....•••-•--------•----------•......-•-•-----••----•-•-----•------•-••-------•-•-•-----•--••••-•---••----------- Date Permit No........... :' .�.1------------------ Issued....................................................... v � y1 • i No......................... Fizz.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........................................O F........ :..:`:. Allpliration for Diupouttl Workii Tousfrnrtion rnmit Application is hereby made for a Permit to Construct (/ or Repair ( } an Individual Sewage Disposal System at: ................_�_j-....-............................................. ......... L-!•----.•.•_-------------------..-4•-- ---•-- - -- ------------ LIC W Lo at -Add e or o. �...... j� . ..... - � .... . ------• - - ------------- �/,. Y. 0 t�,�L.V C Address Installer Address dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........3................................Expansion Attic ( ) Garbage Grinder ( ) p� Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fix t es ........•-----•---•-----•----- W Design Flow............................................gallons per person per day. Total daily flow.............. ........................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter-----_.......... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area _sq. ft. Z Other Distribution box ( ) Dosing ( r ) wi Percolation Test Results Performed b .._... ................................ � S .� ^ W � Y - �--- ..-•----•---•------. Date-- �._`.--= ��---------t----- a Test Pit No. 1.....° ._.....minutes per inch Depth of Test Pit.......i_.......... Depth to ground water...,_ ......... Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....__-___.._________-- 04 O Description of Soil...........`�!=�->)�-�� -�-�::---�;�,a�'Y;�.......................................................................................•-••- --- •--------...................... x r, --------------------------------------------------- -------------------------- •------ ----.-------------------------------------------------------- ----------------------- ------------------ -•----------- ----------------W VNature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------------------------•------•----------------------------------------------------------•----•--••--------•------•-•---------•----••------------........................................ Agreement: The undersigned agrees to install the aforedescribek Individual Sewage Disposal System in accordance with TT rI-s�• the provisions of ,y. ," • `}of the State Sanitary,Yod e undersigned furti:er agrees not to place the system in operation until a Certificate of Compliance has been fss ed the boardhealth. Signed.. ' " ------------------ --------------••-•••--------------• ... -• ..._ Dafe ApplicationApproved BY......................................-----•---•--------------•---•-•--------------------------•- Date Application Disapproved for the following reasons----------------•----------•-----------------------------------------------------------------•••-•---------•---- ---------------•-----•-------••-....--------•-•------•-•-•----------•-----•---•--•-•••-------------•...----------------••--•-----••-------•-•-•------------...--••••----•---•.......................... Date PermitNo--------------------------------------------------------- Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.........7........................................................................ Trrtifiratp of Tomplianre THIS IS TO CERTIFY at th Individual Sewage Disposal System constructed 04 or Repaired ( ) / r/Z s•-S- G i -1 5 0 Aar by - ....--^••------------------------------------------------•------------•--..........----------........._......•••----- at.---•-••.....-•-••--•---•-------_•--•. ......-•••--•----------- --------••-•......----------••------ has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU 107SS CTORY.DATE......... - ...-------•............. Inspector----..... ---- . .�. . .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD ,OF HEALTH . .............................OF....... ........................................................................... No......................... FEE........................ Disposal orku TPAInstructionA Urrmit Permission is hereby granted--- `�:... = -•'.-....................-----...-...---.......---------------•-----•--------.....----....--•--......----- to Construct) .o Repair ( ) an• Individual Sewage Disposal Systeen�_- at No... - .0.......... "...........A...... ....�..S.... -•----•----. as shown on the application for Disposal Works Construction Permit No_____ Dated.......................................... -------------------............... -----------------------•------......-•----.....----- • Board of Health DATE ' �� r-- --•j.-•--•-------•--........ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 0 rl > NOTE&' MILLS "4 M'ARSTONS 0 MA -SHALL CONFORM To D.F-Q.E. 1 :ALL WORKMANSHIP AN 1) TERIALS' WO" (W AS #4CA10 ON PLM A T1 TLE 5 THE TOWN .017 :� RULES' ND BARNSTABLE EGULATIONS FOR, THE SUBSURFACE DISPOSAL :OF .SEWAGE,- LOCU A ND THE REQUIREMENTS -OF THIS,-PLAN. COVE 4w TO 1, ALL BRO RS L To SANITARY:,UNITS ALL'IBE UGHT OUTE, 28 R6UTF 28 ' 11LUEN 58.-S WITHIN 12m OF -FINISHED -GRADE. 7.0. F"OATON 0 a, mm. 0 GRADE IAW 3. ALL 'MASONRY UNITS USED TO BRING COVERS T �SHALL BE MORTARED IN' PLACE.L: JL At 4 ALL ,COMPONENTS ,OF,L THE SANITAOYISY�TEM ,-SH BE� CAPABLE PITW e SCK 46 rw pupc d OF "MTHSTANDING ,H 10 LOADING UNLESS THEYARE UNDER OR /4' M FT.- 9! Mm. PITM I/$- p" 14 MK WTHIN 10 'FT. OF "DRIVES OR PARKING AREAS. H '20'LOADING r'LA"M OF now Lm SHALL 13E USED -UNDER 10 F"L OF DRIVES OR PARKING. )4-6T., AlF A*WL`S�,,. OT UQM" LEMEL STOW BOX _SHALL 6. .,-lFFLUENT P1 ING'FROM DISTRIBUTION R LEACWPI DISTRIBUTION LOtATION MAP 'THROUGH �SIDEWALL OR TOP ON`LV­ ENTRANCE THROUGH MASONRY BOX �'EXTENSION,WILL:NOT ',BE TO COMPLIANCE -NTH .Dd b E Z 7. NO DETER INATION 'HAt BEEN MADE�:AS 66t) ALLON SOM -rAhK RESTRICTIONS OR ZONING REGU -OWNER/APPLICANT 'SHALL LATIONS. ol OBTAIN tSUCH DETERMINATION FROM THE APPROPRIATE AUTHORITY._L SY _STEM;PRQFILE 1, j ,. . '' . I I f. - , I, - :': I r,, H, SEWAGE DISPOSAL 1 ­,�, '­11 1 ­e. �SEElEVY, ;ELDREDGE BOTTOM "OF�,TEST HOLE VERfICAL­CON - ---.I AL OL NOT TO 36LE 'NOTEBOOK # ,ORiUSGS, F`RO8A9LE HIGH YATER 'LEVEL & WAGNER FIELD DE SIGN ,CALCULATION'S CURREN TIONI NG INTER RETA I 11 Nt 'NUMBER OF BEDROO S FEIET MIN. FRONT �kfb'A' CK., M GARBAGE DISPOSAL UNITL SIDt SETBACK 'FIE& jOW ESIMATED F '330 GAL /DAY FEET TOTAL MI N. REAR SETBAck 0 ':GALdBR./DAY GAL REQUIRED SEPTIC TANK, CAPACI 'AC AL SIZE OF' EPTICJANK GAL' TU 1EACH ING AREA REQUIREMENTS SI DEWALL AR E A, iG AL. F. BOTTOM""A 1 0 �'GAL/S.F. REA :LEACHING, CAPACIT-Y (BOTTOM -+ ISIDEWALL) -G S50 AL SOIL'�TESTL .-2!T( 16/2) Q .5) +lt 10 (1.0) DATE S50GA Y CHI CAPACITY LEA NG 'WITNESSED SAME COLA ON' RATE PER TI MIN, NCH ''HOLE -2 OBSERVATION OBSERVATION, HOLE -1 ELEV.,Mi ELEV. "0.00 - ,O-oo AKOUT CALCULATION: BRE 415 To lg&Ar LEGEND L6T ON 00 'o -EXISTING SPOT t VATI LE Km D I X NG''CONTOUR---�-.7----oo------ EXISTI ON FINAL SPOT'ELEVATI '00.0 FINAL CONTOUR 113 S OIL TEST. PIT LOCATION AT ELEV. WATER T ELEV, ATER 'MR TOvvN WA W -4 SEPTIC TANK 0 'AkY-LEACHING P T A �-DISTRIBUTION BOX WATER -�LEV D USTMENT: PRIM AESERVE-LEACHING PIT ,,WATE ST DATE R LEVtL� INDEX WELL INITIAL ISSUE RANGE E WATER 'LEVEL 1T ZON DEP DESCRIPTION :, BY TH 'TO- WATER LEVEL FOR NDEX. WELL, DATE- - NO.' -FOR THIS MONTH rPTC -DESI N: t 'WATER LEVEL �ADJUSTMENT`- E & S E P �­PLAN s IT -DEPTH To HIGH WAI R 'E IN BAI�NSTABLE, MASSACHUSETTS ............................................................ ......... FOR Aj ur IK4s GREEN8RItR INC' C 0 p APPROVED JOB'-NO. LTH BOARD �O E A SCALE: 1472,1 46 N SSOCIATES: -INC IM, ELDREDGE: AGNER A SITE PLAN' I)AM Acm 889 WEST SMET C&tE�Vftll MA -0�6' nOA 01 P17HP" 3