HomeMy WebLinkAbout0017 JONES ROAD - Health 17 Jones Road. l
Ma`rstons'Mills
A= 046—032
i
TOWN OF BARNSTABLE
BOARD OF HEALTH
/�u ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
Date 2 I l o Time: In Out
Owner LAC 176 TBA6K-Y� Tenant \j6CAtj l
Address q �7�I/0��� C Addresss
"&C_C-S TC W?M l O-7- M ILLS f�l
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities Pro _
IUII r 110
�.
4. Water Supply
5. Hot Water Facilities S 3Sti
6. Heating Facilities p ,
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal IJ
16.Sewage Disposal
17.Temporary Housing /vl
18. Driveway Width �j B� s I(0 t o 70 F T
19. Number of Tenants Observed 10 f 9'
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms 3 Number of Veh' s ax)
Number of Persons Allowed (max)
Person(s) Interviewed O"G 1� Inspector
If Public Building such as Store or Hotel/Motel specify here
�
L
• i
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
ii : 2—.v
Date J Time: In oZ I S Out
Owner Tenant
Address Address 1 -7
C (
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities Approved:..
.:
3. Bathroom Facilities MLIJ UtIL
4. Water Supply
5. Hot Water Facilities �.
6. Heating Facilities
7. Lighting and Electrical Facilities rr �
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits , '
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents NO
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17.Temporary Housing /V
18. Driveway Width
19. Number of Tenants Observed 1 IL �� f' C
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms > Number of Vehicles Allowed (max)
Number of Persons Allowed (max) S
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
Date I r Time: In 0 S Out ;,- - U
Owner "`JV' Tenant
Address t' 1�� \ Address 1
CT '
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities L �
v
` 8. Ventilation
J
9. Installation and Maintenance of Facilities
10, Curtailment of Service
_ 11. Space and Use �1- Mil,4tic�-ci(
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal LZ
17. Temporary Housing
18. Driveway Width ✓ t �^_ 4
19. Number of Tenants Observed
PART II G�
37. Placarding of Condemned Dwelling;
Re,rnoval of Occupants; Demolition
Number of Bedrooms 3 Number of Vehicles Allowed (max)
Number of Persons Allowed (max) S
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
&w HOBBsBWARRENTM THE COMMONWEALTH OF MASSACHUSETTS
FORM30 C
OARD OF HEALTH
CITY/TOWN
0
DEPARTMENT
Zo 0 YWO 4-6-( is. �S
ADDRES
G,M s•�• �sv�) 6(,Z— y6 4Y
TELEPHONE
Address '- O wtl_S Occupant_VA-C,A%�j I
Floor T- Apartment No. No.of Occupants
No. of Habitable Rooms c57- No.Sleeping Rooms .a
No. dwelling or rooming units No.Stories —
Name and address of owner o 6L9-?Lg
60u; - L., 0 it.Cesn( . 1_lH (�I 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:
V/ Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting: `O
Hall Windows:
HEATING Chimneys:
VV
Central ❑ Y L N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ 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 s
Bedroom 3
Bedroom 4
Hot Water Facil. Su Elect.:
tacks, Flues,Zejts, ties:
Kitchen Facilities Sink
k. Stove
Bathing,Toilet Facil. ent. PI nit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted >G 10/iv
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 0 PERJURY."
INSPECTOR •4 TITLE
DATE TIME
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 Ieadbased 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.
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Hyannis, MA 02601 a PITNIEV 00%W5 '
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Town of Barnstable
Regulatory Services Department
• RAMI;rABLE, '
"ASS. Public Health Division
1639. ♦�
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
June 5, 2007
Debra Hazard
17 Jones Road
Marstons Mills, MA 02648
Dear Debra,
I am writing in regards to the new rental ordinance for the Town of Barnstable,
Chapter,170 'Rental Properties. We received an application from the property owner to
regster'the rental unit, and the next step would be to do an inspection. The phone
number furnished by the owner to contact you directed me to `Ann' who gave me the
phone number to.the office. However, you were not available and I didn't want to leave
a message on the general mailbox at your workplace. Please contact me directly to
schedule an inspection of your rental property in accordance with Chapter 170—Rental
Properties of the Town of Barnstable Code.
Thank you very much in advance for your cooperation.
Respectfully,
Ca-lit Pie B'arr�ett��1 •
Rental Program Coordinator `
Health Divisiori
#508'862=`4072 ' ; .�^ �w.. t;: 31A.0 ; r
y F
`� �-
FORM30 C&w HOBBS&WARREN Tn THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE H
CITY/TOWN
F
DEPARTMENT c
ADDRESS
tA VAI TELEPHONE
Address ' - l Occupant- pa'',c`-
Floor Apartment No. No. of Occupan
No.of Habitable Rooms— 57 No.Sleeping Rooms o
No.dwelling or rooming units No.S rie
Name and address of owner
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other: Ac
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,Oil, Elect.:
S3jark, F ues,Ve s feties:
Kitchen Facilities Sin
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 IGNED A CERTIFIED UNDER T E PAINS AND
. PENALTIf.SI.F-RFRJURY." �-
INSPECTOR TITLE
DATE � /�" d� TIME
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'arid 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'r 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.
�1,. ov�<s 1Z_osh�
}
°F'IKE t Town of Barnstable
Regulatory Services Department
> BARN WABLE,
MASS. ON
Public Health Division
i639. ��
Arf0 MAC a 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
June 5, 2007
Debra Hazard
17 Jones Road
Marstons Mills, MA 02648
Dear Debra,
I am writing in regards to the new rental ordinance for the Town of Barnstable,
Chapter 170 - Rental Properties. We received an application from the property owner to
register the rental unit, and the next step would be to do an inspection. The phone
number furnished by the owner to contact you directed me to `Ann' who gave me the
phone number to the office. However, you were not available and I didn't want to leave
a message on the general mailbox at your workplace. Please contact me directly to
schedule an inspection of your rental property in accordance with Chapter 170—Rental
Properties of the Town of Barnstable Code.
Thank you very much in advance for your cooperation.
Respectfully,
Caitie Barrett
Rental Program Coordinator
Health Division
#508-862-4072
7) -
L&CATION " SEWAGE PERMIT NO.
VILLAGE
-L
1NSTA LL R'S NAME & ADDRESS
B U It DE R OR OWNER
E2:a�-
DATE PERMIT ISSUED �� 7
DATE COMPLIANCE ISSUED z7
Ly
vztot
i l z,3
��� 7
77
/ _ .. v r, Fa$.....`�. ....�
No. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-.. .....__.. .. . ...._..........OF............................•-----..._..................................................
Appliratiun -fur Uiipuuttt urkii .C�unitrurtiun PPrutit
' *-A IlApplication is hereby'made for a Permit to Construct ( Y')' or Repair ( } an Individual Sewage /pnosal
System at:
�?M- .Q:.. A.=.... ` }'' ----------------------- ------------------------•-•••- 1. .....................................................
Loc lion•Address or Lot No.
N A hj i of
Owner Address
H_.....---•--------•-------------------•--•-------•---------•--------•- ........................ p " ..............................................................
Ga
Installer Address
U Type of Building C A Pt Size Lot.r,0J? ....
o- ....Sq. feet
Dwelling—No. of Bedrooms------3...................................Expansion Attic ( ) Garbage Grinder (<Yo)
aOther—Type of Building ............................ No. of persons..--__..__-_-___-___-______- Showers ( ) — Cafeteria ( )
Q' Other fixtures -------------------------------- -
W Design Flow..................N--------------------gallons per person per day. Total daily flow---------3o_0__.-_.._-_--._-_---..-_---gallons.
WSeptic Tank—Liquid capacitylkta-4--gallons Length....5......... Width---- ...... Diameter_.... -...__ Depth----t--_-.-_---
x Disposal Trench—No. .................... Width-------------------- Total Length_-_--________-__.- Total leaching area......:-------------sq. ft..
Seepage Pit No........I------------ Diameter./_G_dP.'.1t Depth below inlet.....!-'!•_:......... Total leaching area_d_a.4__Q-----.sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) + 2. - />—— 7 7
aPercolation Test Results Performed by-------- ----------- ---•---------••--••--....-•••...............••_..... Date............. --------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.-.-_____-___-___ -- Depth to ground water-----.------.-----.--.-.
G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__._.-_-.______.__-__.
-------- _e----
Description of Soil f -� .X ; ...... .... .`-----�--l=Fhrw-�---/- `- ---- - -----
------------ - ----------- --- - -V 1 '-
W
--------------------------------------------................................................................... ------------------------------------------------------------ ..........................
U Nature of Repairs or Alterations—Answer when applicable..._............................................................................................
----------------------------------•------------------ ---------------------------------------------------------- ._----------------------------------------------------..•----------------------------..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed .'R-'-- .-- -•---...............
Date
Application Approved By••-••. --• .... ------ -- 3 1_i_-_7..7.
Date
Application Disapproved for the following reasons:---•----------•---------------------•-----------------.-•---------------•---------•--.----- --•----------------
-•..............................•--------•------•-------------....------••-•-••---
...-•-------•-----
Date
Permit No. Issued. •3 ............................................
Date
77
... t F�s..... J.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
}
...... .... ...............OF.......................................
Application -for 13i5 orial Nurkii C onr,.itrurtioll Prrmit
Application is hereby`made for a Permit to Construct ( KI or Repair ( } an Individual Sewage Disposal
System at:
ji-�-------4U:.-..---4t.4=........M--t--}•K-------_-------•----- ------------------------ --- /_�-. .....................................................
Location-Address or Lot No.
--------------------- ---Ri__k.... .n......t�-°l a-------'----------------------------------------_____---
Owner Address
a R-=...zo.y.a...................................................................... -----_-------------_ S A.
----------------------------------------
Installer Address
UType of Building G A PF Size ----------Sq. feet
Dwelling—No. of Bedrooms------3-----------------------------_.---Expansion Attic ( ) Garbage Grinder ( )
pa-, Other—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
0.' Other fixtures ----------------------------------------------------------------------------------------------------------------------
WDesign Flow----------------------------=-- ----------gallons per person per day. Total daily flow--------------------------------------------gallons.
9 Septic Tank—Liquid capacity'oq ao_gallons Length-----�_`_______ Width-__5�.......... Diameter-----5--......... Depth---A�_.........
xDisposal Trench—No_____________________ Width----------_--------- Total Length-................... Total leaching area--------------------sq. ft.
Seepage Pit No........e............ Diameter":"'µ,K:!.^_...._. Depth below inlet.....j.�_'.._.__.__ Total leaching area_F_a.<:-__.._sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) 2
-" Percolation Test Results Performed bY.......................................................................... Date_-------------------------------------..
a
Test Pit No. L_______________minutes per inch Depth of Pest Pit_................... Depth to ground water---_-_---_-_--__--__--.
Lh Test Pit No. 2................minutes per inch,,. Depth of Test Pit-------------------- Depth to ground water-_----_____-_______-
- - �I r
Description of Soil � � e ;...... �+�---- `------ �'----- �?'G-- ----- --- ---- ------------_---
W
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
------------------------------------------------------ •---••--_-----•---_--•--•-••---•----------------------=-------------•------•=•--•------------------------------------- -------------------------
Agreement:
The"undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed- . = -----•••. ---- ------------------------------------- --------------------------------
te
Applicatio:' proved BY ��G� -- '�I 7a�
---- ---------
Date
Application Disapproved for the following rea'sons__________________________:_.________.__._______.-____-------•-•-•------------------•--•---- -•---
_______
---•----------------------•---------••• ---------------------------------------------------------------------------------------------------------------------------------------------------------------
Date
Permit No......................................-•• ,� 7
-------------- Issued--------.------------�-�--=----...-----..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
~ .....OF......... .. ..... ''L......:.......,....................................
If
%Lkn iliratr rrf �uut li err
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V1 'or Repaired ( )
by----------------- ••--; °A_ .1 ---------------------------------------------------=--.----------------------------------------------.-.--------------------------------..--•------------
Installer
at.......... ---------70__40--- �-------------.M- At_- 4.8-------------------------------------------------------------------............................
has been installed in accordance with the provisions of A i1 XI/o� The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. __ Xl�) The
dated--. _`f�_'. ._____..__.__.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WI L UNCtION SATISFACTORY.
/�//
DATE - / .7 Inspector!___�------------------•=----------------------•--...--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(A, .............1/ '"'ZPl�L.....OF.--.......-..... lJ
No. ........ FEE
Bi5po5tt1 Morkii .01on5trurtion Vrrntit
Permission is hereby granted--------1)........ n J t...
to Construct (V or Repair ( )''an Individual Sewage Disposal System
atNo.---- f ' -------. a I`J' i.----._ .......... -------------- -------------------------------------------------------------------------------
Street
as shown on the application for Disposal,Wor, 'Construction P IfiI No.- .._. _..._IV Dated----k"_�f_`-7-7__._.___..
Board l�44III of Health
DATE..... ------------------- ---------------------•
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ''
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