Loading...
HomeMy WebLinkAbout0416 OST.-W.BARN. RD - Health 41 I Ost. • 3 � Ma.rstons Mills \ A= 122— O l l y' I BUILDING DEP T. P. J. Garrity, Trustee of the PJG Trust AUG 13 ?021 garritypi60ahoo.com 54 School Street N OFBARNTABLE Belmont, MA 02478 (617) 489 6881 8 August 2021 Town Manager,Town of Barnstable Barnstable Building Department Services Administration Building Building Commissioner 367 Main Street 200 Main Street Hyannis, Massachusetts 02601 Hyannis, MA 02601 Attention: Mark Ells Attention: Brian Florence, CBO Re: Violation of Zoning Ordinance(s)and creation and maintenance of a nuisance Gentlemen: Please be advised that Kaitlyn E. Lanoie,the title holder/owner of 416 Osterville/West Barnstable Road 02648 is occupying and/or leasing, using and maintaining this property contrary to the Town's Zoning Bylaws Section 240-14. Located in a residential (RF)zone,the .84 acre parcel located on the Assessor's Map 122 as Parcel 11, has extensive frontage on Penny Cross Drive, a private way. Prior to December 2918,the heavily treed property was improved only with a very small, 693 square foot,two bedroom and one bath ranch house. After the property was sold, many mature trees and shrubs were clear cut to allow multiple motor vehicles(probably unregistered and uninsured)to be parked on the long narrow ' o�t rontmg o-A� irros e: The-view from my backyard is that of a used car lot/junk yard. From 2019 to 202 depreciated cars,trucks,vans, and trailers were added to the motor pool along with poorly constructed structures and equipment. This congested compound fronting on Penny Cross Drive does not appear to be fenced-in even though many types of farm animals seemed to occupy the several shanty sheds and other enclosures that are located a short distance away from my property line. There are enough animals being housed on this lot to qualify as a small farm,for example pigs,goats, poultry and dogs, etc. Loud noises at all hours originate from these premises;and their'free range'chickens constantly trespass to forage in my two raised gardens. More disruptive than the noise,fumes, dust and odor is the ugly, unkempt, unsightliness of the entire parcel that literally looks and acts like a junkyard. The present use came into fruition gradually without any notice to abutters or,apparently,the Town. If there is a legal remedy to cure this injurious, obnoxious,and offensive use and occupation, I respectfully ask that a view be taken of the situation and a Cease, Desist and Abate Order be issued forthwith. I see nothing under Sec 240-14 of the Zoning Bylaws that permits the uses mentioned above. There appears to be more than one principal residential building as well as businesses operating from the premises. Please check and validate whether or not the owner/tenant has applied for special permits from the Zoning Board of Appeals to use and occupy the premises as it now exists;further I would suggest that the Board of Health also inspect the property and the animals thereon. If such uses are not permitted, I would ask the Town to take all necessary steps to insure that all illegal items,structures and farm animals are removed. 416 Osterville/West Barnstable Road has morphed into an untidy, detrimental nuisance that has effectively caused the diminution of market values of all real estate parcels located in and around the immediate neighborhood; plus the big trees can never be replaced. Very truly yours, `lle) Commonwealth of Massachusetts 9 :. ;P Title 5 Official Inspection FormM 'l l Subsurface Sewage/Disposal System Form -Not forVoluntary Assessments/ =" 1e &IeS4 dcilriip�ikl 4ej Property Address / 4 C l v1 G' Gd / ��I v Owner Owner's Name information is � rs' /0 required for every ; page. City/Town State Zip Code Date of Inspe6tion I•� Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. mportant:When A. Inspector Inf r ation S1 /3�f(2fv *filing out forms on the computer, c / /,se, use only the tab �-77 key to move your Name of Inspector O / cursor-do not V[ G use the return Company Name — l Q Frey. /C) O t�J Company Address 4F—Q> 0.1 k Vd— City/To �O� .180 , 2109� State / �O Zip Code rem / �!i Telephone umber License Number B. Certification certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); i have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems_After conducting this inspection I have determined that the syst m: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails /o iy /� Inspectors ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable. and the approving authority_ Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ?i;la 5 O"dal Inspection=om:SuCsurace Sewage 0!sposal System.page t of is ;Sinsp.dx-rev.7126/2018 �� Fi IS..^1•.: df:;. ell' Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments /�o Os 71r01 At (✓ Property Address J Owner Owner's Name ��/� /j�J � information is required for every (Q.,.r4o s / " //4 /1 a6 v OQ /0 6 �$ page. Cit rTown State Zip Code Date of In ection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System P ses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: One or more system components as described in the'Conditional Pass'section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes'. "no" or"not determined" (Y, N, ND)for the following statements. If"not determined,' please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): [5it75p.tloc-rev.726/20 18 Title 5 Offiaai irspecaor:Fo m_scosurace Sewage 7sposa System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /V Owner Owner's game D p�C (,f(/ �Q O O information is a/s .s I required for every //�� page. City/Town State Zip Code Date of Insp ction C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 "times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Corditions 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. a. 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: t5insp.doc•rev.7/25/2018 Title 5 Official:nspecaon Foar::suosur`ace sewage oisposai system•Page 3 of 18 f Commonwealth of Massachusetts Title 5 official Inspection Form r1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Os4ewdt� ls- Property Address a rhr/40�? Owner Owner's Name information is Q rs�Olin r l J' pa b qa /o S required for every page. CitylTown State Zip Code Date of Insp ction C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: **This system passes if the well water analysis, performed at a DCP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes N;0< Backup of sewage into facility or system component due to overloaded or logged 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 Title 5 01ffl0@HnSCeCnjQ1 Fom:suosuGace sewage Disposai System.?age 4 of 18 t5insp.cac•rev.7282018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IW4 Property Address /4 y Owner Owner's Nam��C, ��jj /'[[`� Q /� iequiretion is a4os //f �/�b 74v /0 t o /9 required for every page_ City/Town State Zip Code Date of i pecti C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: [� Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] n he system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. 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. 5) 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 0.4. Yes No the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection El Area—IWPA)or a mapped Zone 11 of a public water supply well 'itle 5 ClftiSl hspecton com Subsurface Sewage Disoosz!System•Fage 5 of 18 t5insp.doc•rev.7262018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments/ / 4'r-0 At Property Address PC;el V✓I Owner Owner's Name S LV V /� X9 If information is a /ft 7 required for every State Zip Code Date of I pection page City/Town C. Inspection Summary (cost.) If you have answered"yes" to any question in Section 0.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions; depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has een 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)] Title 5 0�ficiai inspen on,` su5scrface sewage Disposal system•?age 5 or 18 t5insp.dx rev.7/26/2018 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name p information is required for every page. City/Town State Zip Code Date of Insp ction D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): a a�Q DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: / /000 Ir/� oh ^ a.('/d c f G''"v tf P�4C-*4,0 ti � ,,/�. j2 nL -1'+ S L( '%//c�7"if LA4 0 VU — 0 NAeroent residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Fig, o information in this report.) Laundry system inspected? Yes No No Seasonaluse? es ❑ Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ] Yes o Last date of occupancy: Date Ti,5_kcal irspecaon=cm.Scbsurace Sewage Dtsposai System•Page 7 of 18 t5insp.doc•rev.726i2018 Commonwealth of Massachusetts - � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assess ents Property Address Owner Owner's Name information is OI/l T�As required for every page. City/Town State Zip Code Date of In pection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: Was system pumped as par of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.dac•rev.7/262018 -itie 5 Coda Inspection Form.SubsJrface Sewage Disposal system•?age 8 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IVY Property Address 94, 41� 016 01 Owner , Owners Name r5 f ifA4 O 6�e /O ,� ` g information is required for every page CitylTown State Zip Code Date of In ectio! D. System Information (cont.) 4. Type of S m: Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology"Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: IX/ 1991f Were sewage odors detected when arriving at the site? ❑ Yes o 5. Building Sewer(locate on site plan): Depth below grade: feet o Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): -itle 5 cal inspecow Fom.sucsurface se�age Disposai system•Page 9 of 18 t5in3p.doc•rev.V2612018 f Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a4eKildl- Property Address ON 41 Owner Owners Name information is Grs' Ms rArequired for every page. City/Town. State Zip Code Date of inspection D. System Information (coot.) 6. Septic Tank(locate on site plan): Depth(below grade: feet Material construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank s metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Ll Yes ❑ No 5 Dimensions: r � Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle - /- O How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �r79 /?o / a N �, �H d �s t✓� 5'00 �or��'to✓r , /lam ea4-5 Tore 5 Jf`aal Mspecnon=orn:Sucsurace sewage Disposes system•?age 50 of IS t5insp.doc.tev.7/26/2018 t\ Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments O.S-lerv,114e c/ rrhs b�cled Property Address Owner Owners Name /r /✓�� / information is A/4 r-s hs /� �4 [ � /$ / required for every page. City7own State Zip Code Date of In pecticifi D. System Information (cont.) 7. 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.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day "i to g `ca:fnspewon=om:s:bsc`ace Sewage Disposal System•?age t t oft 8 t5insp.doc•rev.7t2W2018 c Commonwealth of Massachusetts Title 5 Official Inspection Form eRl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Qs,�e�vi l�e G✓ ar�1�S� �� Property Address 06o"I4V Owner Owner's Name information is required for every • page. City/7own State Zip Code Date of Insp ction D. System Information (cons.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): __ it� Depth of liquid level above outlet invert � 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.): o C(s ?:te 5 oi5cai:nspenon Form.suosurtace sewage Disposal system•?age 12 of 18 t5insp.doc-rev.7262018 Ii I� Commonwealth of Massachusetts t� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T1(00 OS-4wedle- 6v1 Sq..,of jec-J Property Acdress Owner Owner's Name information is GI�s�ON s /• 3 �/QZb T O 21)frequired for everypage. �ityfTo`^`n State Zip Code D. System Information (cost.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Non Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or'alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: �� 14/ a ! / �, leaching pits � ber: 7"O ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: (1 overflow cesspool number: ❑ innovativeiaitemative system Type/name of technology: Tile 5 omf ai insx.:for=or,:Suos,r.'ace sewage oisposai system•Page 13 of 18 5insp.doc-mv.7/26/201,8 'i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SL4ek'Ile (✓ &frtf 4114 �d Property Address ReA$11 140 v! Owner Owner's Narre / Q information is regjired for every pace. City/Town State Zip Code Date of Inspe 'on D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 0 for keg C/1#4 �1. yC 1-6 CPI- fit G✓r SO/� �l v1 a0 Jl - C�l 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Numbe-and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materia^s of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure; level of ponding,condition of vegetation, etc.): -me 5 .ca inspection Form:Sucsu'ace Sewage Disposal system•?age 14 of 18 t5insp.doc•rev.7262018 ,I i Commonwealth of Massa chusetts Title- 5 Official Inspection Form ,,� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments // ry S .4v Property Address Owner Owner's Name information is t required for every page. CityRown State Zip Code Date of nspec on D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.'/26/2018 Tiue 5'maa nspecton=o�..Scosudace Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y/4 s ��& Ct/ Property Address / Owner Owner's NarneN. information is '/Q -equired for every rsTO✓� r 0 6 `�'� /0 /O page. City/Town State Zip Code Date of 19spectidn D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks enchmarks. Locate all wells within 100 feet. Locate where public water supply enters the but g. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately I ' AI I i II I I n ! Qiive I T sPP�, C!4-�p � L � 3 p11-3 �t pil- -3 Y d3 `0 �d- -37 I t5insp.doc.rev.712612018 ?ite 5 `dai irspecnon=cnm:subsurface sewage Disposal system-Page 16 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L-ek Property Address 1 ... 1-4- 4 011 Owner Owner's Name ,y� Vvl information is _1 _M f , ' c `;0,(4 �/�l /0 6 /e required for every O►✓f 7�D ,/ (� o / ( I page. CityfTown State Zip Code Date of Inspectio D. System Information (cons.) 15. Site Exam: Check Slope Surface water ❑ Check cellar Shallow wells ao Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked; date of design plan reviewed: Date ❑ erved site (abutting property/observation hole within 150 feet of SAS) Checked with local Boar e Ith-lain: Lrl Checked with locai excavators; installers - (attach documentation) L.1 Accessed USGS database -explain.- You must describe how you established the high grouno wa er elevatio .� tj go %rro44w�waoo� Before fling this Inspection Report, please see Report Completeness Checklist on next page. $insF.dOC•n:v.71262018 `tle 5-maai rspecacr Fa-:Subsurace Sewage Disposes system•Page 17 of 18 Commonwealth of Massachusetts MOP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ile (.1es Property Address d Owner Owners Name G�, information is required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. I�YCInspection ertification: Signed & Dated and 1, 2; 3; or 4 checked Summary: 1, 2, 3, or 5 completed as appropriate 4 allure Criteria) and 6 (Checklist) completed D. System Information.- For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 5insp.doc-rev.7126/2018 TIUe 5Qffiaai mspemcn Po.—..suDsuoace sewage Disposai Syscem-?age 18 of 18 TOWN OF BARNSTABLE I BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date 2 (,� Time: In � ./ � Out l Owner. Tenant Address Address Ll 0 S� W Corn lian Remarks or Regulation# Yes 1140 Recommendations 2. Kitchen Facilities Appm"d: 3. Bathroom Facilities wo � �� 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal O 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed 8 U PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms �-- Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address Owner Owner's Na 0 me information is i�G, f�ONf ��ftln�specbon required for every page. Ity own State Zip Code Date Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1, Inspector: I only the tab key to move your ewsor-do not use the return Name of Inspector r//� _ key. � l� /O Company Name/ lot 3 m U Company Address �aS j�I� Clty/Town LSO /J 117117 141-/ / State Zip Code Gfo Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Kr-Passes ❑ Conditionally Passes Fail ❑ s ❑ Needs Further Evaluation by the Local Approving Authority Inspect 's signature /v Date k 03 The system inspector shall submit a copy of this inspection report to the A proving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the systempls a shared sysfecn or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submdfRe report to the appropriate regional office of the DEP. The original should be s"nt to the s�stem owner and copies sent to the buyer, if applicable, and the approving authority. r- -:) ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ins•0S/08 Title 5 Official Inspection Form:Subsurfac?Sewage sal System Pa I of 17 r ge f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments W 6 0Sr-111 Property Address Owner Owner's Name ' information is kl s //� �c /Q a� � required for 4 every page. Cityrrowwn State Zip Code Date o nspe 'on B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System P ses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leakingand if a Certificate f Compliance indicating that the tank is less than 20 years old is available. o ❑ Y ❑ N ❑ NO (Explain below): 15ins•09r08 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts IVTitle 5 Official Inspection Form -- Z4 040�1 Ae Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address #O✓ Owner Owner's Name J / !� / information is //�G�ST t)N� // "/ S //%�✓/ t b�f� !tJ a� > required for every page. Cityfrown State Zip Code Dao of In pection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh lsins•os�oe True 5 official Inspectlon Form Subsurface sewage Disposal Syslem•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 77 Property Address J �0�G Owner Owner's Name /� information is /41a" -s 1' 111 required for Q 6[f ,(O oZ /-I every page. City/Town State Zip Code Date Ins 'on B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. I Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Yz day flow i5ins•osroe Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address / Owner Owner's NamiI�J�J�✓ 7'V�s i�/ iequiredionis / b '� lfl required fw every page. Cityfrown State Zip Code Date of nspe on B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L� y portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•owo8 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Umrjo- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address Owner Owner's Name s� S information is required for / a2 6 /0 every page. Cityfrown State Zip Code Date if Inspe4bon C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yees/ No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Ea Were any of the system components pumped out in the previous two weeks? ❑ E3"`� Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? �❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) L�1 ❑ Was the facility or dwelling inspected for signs of sewage back up? L"t ❑ 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 een 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)j D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t&ns•osroe 7iue 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z7v� S�e✓v��le �G'✓'K.r7'�b� �� Property Address O✓ Owner owners Name / /1 information is /W 0.1 w 1� a required for every page. City/Town State Zip Code Datei6f Insp ction D. System Information Description: 100c (T) 1,12,1_5- Cl) 6 X-y Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 9-- Imo Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes o Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Ye o Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: [sins•owoa Title 5 official Inspect on Form:Subsurface Sewage ofsppsal Syslern.Page 7 of 17 I f Commonwealth of Massachusetts z, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for Wa"A V7S / AW 0,4 t�y 1,0 l/D every page. City/Town State Zip Code Dait—eo nspeafion D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sys Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): tams•once Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page a of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address � Owner O �4f-Aof wner's Naminformation is required for �� � C d 1,52 evary page. City/Town State Zip Code Date o nspe ' n D. System Information (cont.) Approximate age of all co onents, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes to Building Sewer(locate on site plan): Depth below grade: feet 4� Za rial o nstruction: st iron PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade. feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 15ins•o9tott Title 5 Official Inspection Form:Subsurface Selvage oisposw System•Page 9 of 17 L Commonwealth o Massachusetts Title 5 Off cial Inspection Form Subsurface Se/wage D sposal System Form • Not for Voluntary Assessments Property Address Aj� Owner Owner's NamW ration is regou red for / it S � //9 every page. Cityrrown State Zip Code Date o(Inspec6on D. System Information (cont.) Septic Tank (cont.) �j Distance from top o sludge to bottom of outlet tee or baffle f/ Scum -hickness Distance from top o scum to top of outlet tee or baffle Distance from botto n of scum to bottom of outlet tee or baffle How were dimensio is determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as relat d to outlet invert, evidence of leakage, etc.): PcIf dl'f rV7 MO/ r/QYcle G's —AfS 7/to17. A10 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 I&ns•og/U Time 5 Official Inspection form:Subsurface sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S stem For -Not for Voluntary Assessments Property Address //0 V/C'( Owner Owner's Name I ,� information is i//�� required for ✓ �'lS- 5 / "l/S A( cb2z every page. City/Town state Zip Code Date/of Insp4ction D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No I5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 g,\_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L 0,4r4lle- Property Address Owner Owner's Nainformation is me `/ required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on sit@_Plan): Depth of liquid level above outlet invert �ve� 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.): b � ve AV soled kv Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: tsins-o9me Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form IVSubsurface Sewage Disposal Sys em Form /- Not for Voluntary Assessments (/�//l Lf�.6 �S e (,-x sus Property Address Owner Owner's Na information is f f A a /� required for Name every page. City/Town State Zip Code Date of nspection D. System Information (cont.) X iv Type: - X -/ AC$9, leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): S47 "5 lets rC Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•OW08 Title 5 Official Inspection form:Subsurface Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Z#6 01-)l�Vllle (,(//- /�) / Property Address / reOwner owner's Nam��4::ws-k urired on is -i f A4' required for � # every page. City/Town State Zip Code Date of pecti D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t&ns•oevoe Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments q4 Property Address Owner Owner's Name ✓ XW inquiredon is �, s a a 9 1Vrequired for every page. City/Town State Zip Code Date oYinspecdon D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where 'p,d6fic water supply enters the building. Check one of the boxes below: and-sketch in the area below ❑ drawing attached separately -3� Fkoh f —� 14 Lr or i T If 6-Xb Pr;4 Gx 15ins•ovoa Title 5 Official Inspection Form:Subsurface sewage Disposal system•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' Property Address ©/c�/ i Owner Owner's Name � ! information is .//I�Q/S l4 f � required for r/f 1/V r /04�li /0 every page. City/Town State Zip Code Date of Inspidiction D. System Information (cont.) i Site Exam: ❑ Check Slope ❑ Surface water � � �•. / � ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date I ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: I i ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: I I iYou must describe how you established the high ground water elevation: i i — v i I l Before filing this Inspection Report, please see Report Completeness Checklist on next page. tsins•Oy06 Tide s Official Inspection Form:Subsurface Sewage Oisposw System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' z{/4 x.J Property Address ✓L Owner Owner's Name information is required for every page. City/Town State Zip Code Date of I pe on E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed 0 Sy m Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ' !sins•09/08 Tine 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -_ i TOWN OF BARNSTABLE Approved: �i I Z�oc� BOARD OF HEALTH MLDCed: _ ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 3 ( 11 Z 8 0 .4� Time: In 2 ( �c Out Owner y t2 M-kN "O izc� Tenant cs V-N �Au r LN D Address I0U CL�J(S P—Q, Address Lt_tt ice/A R-S-.6 Q ►L L S � a 32 OZ (- Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities ,� Z- 2 O 6. Heating Facilities CZA G-C 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service t/ 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing /vA- 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Z I Number of Vehicles Allowed (max) .3 Number of Persons Allowed (max) L , Person(s) Interviewed Inspector If Public Building such as Store or H tel/Motel specify here TOWN OF BARNSTABLE /01 BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 3 t 1 I Z 00 Time: In 2, J ,'. gut 30 Owner \�I o fL M A V3 y�� Tenant We a Imo.A Address es C(-v 6 eO . Address - l i(9 0(5-T I P-\1 I LL r,-, - w t S7 C Q tiJ Z e� �/ 1 LrL �� /�► 9 A P-S'(o 13 S- 1 �'1 1 1.L S f O 2C�32 OZ (1c. Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply s 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation r 9. Installation and Maintenance of Facilities 10. Curtailment of Service i 11. Space and Use l 7 ! fF n 12. Exits i 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing tiA- 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; ��^'�rn, Removal of Occupants; Demolition --Cu CGS?� Number of Bedrooms _ .3 2•- � �� Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector S If Public Building such as Store or H tel/Motel specify here I 'i r t FORM30 C&W HOBBS&WARREN TM THE COMMONWEALTH.OFMASSACHUSETTS BOARD OF HEALTH CITY/TOWN W �-1t ra L TN o DEPARTMENT G C) A to ADDRESS TELEPHONIf G//(D G57• iry �9n -dtaa� 6_cc" pa PA t-j Ld s4 i Address _ _ ccupant�H�� 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 0 9- M-A )A__E_ 140 P%0 I W O C LU 6 IZ40•• C F_yl-%EL;N1i(,LG MA O"3 Z Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish / Containers: j/ Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B [:IF ❑ M , Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: V Dampness: V Stairs: r� Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y 11 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: r / 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 . V Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Safeties: Kitchen Facilities Sink / 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 V0_C,-C 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 PERJURY." INSPECTORTITLE JOAL W-M DATE /12/000 TIME A 6 THE NEXT SCHEDULED REINSPECTION � dT A M P.M. � - 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,,when fo.und 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. B000uoo Chapter|i 105 CMR 410.100through 410.620otate minimum requirements of fitness for human habitat on, any other violation has the potential 10 fall within this category in any given specific ��situation but may not do | in every case and therefore is no1ino|udod in this listing. Failure to include- ohuU in noway be oonokued auodetormina\ionthat other violations or conditions may not be fo6nd to fall within this category. Nor shall failure to include affect the duty of the local health official Vo order repair or correction ofouo6'vio|oAion(o) pursuant to1O5CMR410.830 through 41O.833 nor shall failure Vz include affect the legal obligation of the person Vz whom the order iu issued Vz comply with such order. p0 Failure to provide a supply of water sufficient in quantity, pressure and temperature,*both hot and cold, to.me,et the ordinary � needs of the occupant in accordance with 105 CMR 410.18 0 and 410.190 for a period of 24 hours or longer. | (B) Failure to provide heat as required by 105 CIVIR 410.201 or improper venting or use ofaspace heater orwater heater as prohibited by 1O5CMR410.200(B) and 4102O2. ' � (C) Shutoff and/or failure ko restore electricity orgas. � (D) Failure 10 provide the electrical facilities required by1O5CMR41O.250(8). 41U.251(A). 41O.253 and the lighting in com- mon umarequiedby1O5SMR41Ci254 (E) Failure 10 provide a safe supply ofwater. . ^ � (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CIVIR � 41O.15O(A)(1)and 41O.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 ond410.452. � (H) Failure 0m comply with the security requirements-o.f 105 CIVIR41O.480(D). . (|) Failure to comply with any provisions of105CMR410.6O0. 41O.8O1or41O.6O2 which results in any accumulation ofgar- 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 or1othe 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, 105CMR460.000. (See M.G.L. o. 111 @6D 190#hmugh 199j � (K) Roof,foundakion, or other structural defects that may expose the occupant or anyone else Vofire, bumn, ohouk, accident or other dangers or impairment 10 health orsafety. (L) Failure to install o|ootrioa|, p|umbing, heating and gao'bumingfaoi|ihon in accordance with accepted p|umbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and41O.352. so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health orsafety. (M) Any defect in oaboatoo material used as insulation or covering on a pipa, boiler or furnace which may result in the release of asbestos dust orwhich may result in the release of powdoed, crumbled o/pulverized asbestos material in violation of 105 CIVIR410.353. (N) Failure to provide o smoke detector required by1O5CIVIR41O482. � (0) Any/d the following conditions which remain uncorrected for period of five or more days following the notice Vuor knowledge of the owner of said condition orconditions: � (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 Vu provide a washbasin and shower or bathtub au required in1O5CIVIR41O.15OVV(2)and 41O.150(A)(3)orany 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 p|umbing, hmating, gmsfitting, or electrical wiring standards that do not create an immediate hazard. | (4) Failure to maintain aaafe handrail or protective railing for every stairway, porch baloony, roof orsimilar place as required by 1U5CIVIR41O.503(A)and 41O.5O3(8). ' (5) Failure Voeliminate mdents, 000kmuohox, insect infestations and other pests uorequired by 105CIVIR410.550. | � (P) Any other violation of 105 CIVIR 410.000 not enumerated in 105 CMR 410.750(A)through (0) shall be deemed to be a con- clitionwhichmayondangerormate/iuUyimpui/thohea|thoroadetyandweU'Uoingofun000upan\upontUeYai|ueoftheownor Vn remedy said condition within the time uo ordered by the Board ofHealth. , ^ | � � � � ` . ' h TOWN OF BARNSTABLE 1/~ LOCATION 41 (p LA�• i-.�VOJV�'QOSEWAGE #q"'P 1E RYILLAGE m�l.�� ASSESSOR'S MAP & LOTjgeR �-J// INSTALLER'S NAME & PHONE NO ��"'V SEPTIC TANK CAPACITY P LEACHING FACILITY:(type)9�, l�1.��1 (size) 2 5 NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WA FR � BUILDER OR OWNER �,�\SN-No L DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No A- . R I - �. Na. - .. Fis....V............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Divi-Voiial lVvrk.5 Tomitrnr#inn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( -<an Individual Sewage Disposal System at cationVkb s�� 2 ............................ .... ..........."V," ° t Owner l Address WW1 .... .... ��� �--- .................. Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ......... W Design Flow............................................gallons per person per day. Total daily flow..................................._...... gal Ions. 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1-_----__-.--.-minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix ------------------------------------------------------------------•-------------------••••-•--------.........-----------•......---------- ... ....----.------ 0 Description of Soil....................................................................................................................------------------------------.................... x U. --•---------------------------•--------•••----------•-----••---•--...--------•----•---------.......-•---------------------------•------------. ......................................................... ----------------------------------------------------------------------------------------------- ---- l� U Nature of Repair Alt tions—Answ when a plicable. LJ � ......! __.__.... - I- --------------- .. - --- - ............................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system_ in operation until a Certificate of Corngw ehe board of health. Signe --------- Application Approved By .....- � ,! .. --------. ... .. — ... .................. .........'-----'Dace--'—'----...... Application Disapproved for the following ............... -' ........................ ............. ' ........ :..... ............... ... ---- -------------- ------.....................------------- .------------------ Dare Permit No. Issued a A :, 0,1, - �� - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirtt#iun for Disivutittl Workri Towitrur#iun rrrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( 4--)a Individual Sewage Disposal System at: y,(� ----- ----------- =•Location-_Address or Lot F Owner Address Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building .----__ No. of d a YP g ---------------•----' ---.Persons-----------...--------- ---Showers ( ) — Cafeteria ( )Other fixtures --------------------------------------------- ........... 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 tank ( ) aPercolation Test Results Performed by-------_------------------- ---•---••-----------•-••---•-•-----------•••• Date....................................... Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 40 Test Pit No. 2................minutes per inch Depth of Test Pit--.--.-..._--------- Depth to ground water........................ 9 -------------------------------------- .................................... ---------------••-------......................................................... 0 Description of Soil........................................................................................................................................................................ V .........................................................•---------------•----••-••-•------•---•------------••-•----------------------------••....--------=-------------•-----------•-.---------------- -------------------------- ------------------------•--.._........---------------------------------- --------------- a plice.--l � `c.. . C..-.... . � ...Alterations—Answ�when ab �U Nature of Repairs-o . ....................•--••••••••---- ........ .............. ....... ------------------------------•---------------------------------•---------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com;Iiane(has beenzsssued'by the board of health. Signed::�; -� - -� ----------------------------------------:-- ----' l Dare Application Approved By ---- l .1/':1,�/,�._a ^. ..... /_. .�'(=- ................ ........................................ Dace Application Disapproved for the following reason ........... - t --«s" ---------------------------- ----------------------- f ! ..........------------------- Permit / Dare No. ./....t �....._............. Issued ..,.1.. �-... ............. ......................... C THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Prtifirate of (foraptianre .._- - wage Disposal System constructed ( ) or Repaired ( ) b T' W IS TO CERTIFY;--That the Individual Se.� Di at .......... W........... ....s ....... �i!� I Sfal el.....-W.............................V _. ..:..... .. -...................... has been installed in accordance with the provisions of TITLE 5f.f The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...... .......... "a..... .. dated ......._......_-------............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UEA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _, -- - � i DATE--------- .........------- --��. ......... .. ......... Inspector/ .-. .-.�% G9 = THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH G� � J TOWN OF BARNSTABLE ' a- NO.....�....r..........�.. FEE......................... Diupnfittl urkii-�C °omitrur#ion lernti# Permission is hereby granted.�_�t -. � "'( {�1,.. ----•-------------------•----"............................. to Construct ( ) or pair ( V)an Individual Sewage-Disposal System(5— �-;, , M, M treet' as shown on the application for Disposal Works Construction re mit No !-:!.._. �1��Dated..-___� ' S w--- �•-Y•-••. Board of Health "PATE............./ ... � .............................. FORM 3890E HOBBS 6 WARREN.INC..PUBLISHERS FORM 30 C&W HOBBSB WARRENrn THE COMMONWEALTH OF MASSACHUSETTS BOARD OF LTH CITY/TOWN W D P' ARTNffT ADDRES � // ' G1 M SV 0y`0 � � ���1J`yl K7 d/ r_ l TELE Address W � )�'°',�'" _u_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 Remarks Reg. Vio. YARD Out Id s.: Fences: Garbage and Rubbish Containers.- Drainage I� Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: 421 Walls: -- Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Wry 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 11220 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.: S, Flues V Safeties: Kitchen Facilities in 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 gqNED AND CERTIFIED UNDER THE PAINS AND PENALTWS-9"ERJU INSPECTOR TITLE DATE �1 15— TIME V 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 II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation.has the potential to fall within this category in any given specific situation but may not do so -in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water-sufficient in quantity, pressure and temperature,-both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage,,rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. O presence resence 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. Failure to install electrical plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, (L) a , p 9, 9 9 9 P P 9 9 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. �U 7 o0 y�� 0 f _ • �`° LOCQT10 5EW&C4E PERMIT UO. iPIS f�L ER*S IJWFE ADDRESS BUILDER 5 Q &V AE ADDRIe SS DATE PERNAIT ISSUED DATE COMPLI W-ACE ISSUED ; �� i d��l �,� �� ar ,_ .�, ,: 7 .� � .a, _.____. �� - �, fir,''�� L' i i i _ , Ir._ No.---,j-- ...... ...... .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH -for- tti gar Cnowitrurtton Vrrmft Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal Sys em at .... -�/ - Q//�,� ��/I.J_.. C%�"�t GA�C/(c� o I�?u.-----•......o-P'a-•S Location-Ad .ress or Lot No. ......---•-•--------------------------• ------------------. -----------------------------•---------------------- W wner Address Installe Address Q Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. P4 Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------------- Depth---............. xDisposal 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.......................................................................... Date-----------------....------ ----------- ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water...___._--_--__._-._---- (� Test Pit No. 2................minutes per inch Depth of Test Pit._______-.•_-______- Depth to ground water--...._________-____-.-. ------------------- ---•--------------------------------------------------------------------•---......................................................... 0 Description of Soil------------------------------------------------•------•---•-------•---------------------------------------------------------------------------------------------------- x x ---------------------------------- -------------------------------------------------------------------- -- ----------------------------------------------- U Nature epairs r ,�iterat' ns—Answ hen applicable._--. .. _ __ _._.. _11'0. ................----------------- '�'1'Y f o -u ----•------------------------------------------- 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 b issued by the board of h al 10 t ned- •--- -- ----•---•- Date Application Approved By--"------- ----- -•--- --- ---- .. ----- ... `. -- -- ------------- - Date Application Disapproved for the following reasons:--•-------------------_ - ;....... -------------•--•---------------•---•----------------------------•-------------•--------•--.-----------------••--••-------------------------------.------ -•---•----------------------•------•----•--- ate Permit No......................................................... Issued......... •-•------ ........ No.._.3�d..... F:m$.. .................... THE COMMONWEALTH OF MASSACHUSETTS _BOARD F HEALTH ....-..OF....... .... 1n, .....�........... A.VVIiratinn -for Dhip al Works Tnnitrnrtinn Vrrnsit Application is hereby made for a Permit to Construct ( ) or Repaii 4 ) an Individual Sewage Disposal Syn at• . Location-Ad ress or Lot No. E /w�ner Address p Installer �`+ � Address Type of Building / w Size Lot----------------------------Sq. feet }v Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic6' Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ----------- --------------------------------------- ---------- ---------- W Design Flow...........................:!nz.............gallons per person per day. `Total daily flow-_ __-__--.--____------.-_gallons. USeptic Tank—Liquid capacity..±.. .:;gallons Length________________ Width_.__....._..... Dia meter......- <._._K.Depth.-_....__..._.. � xDisposal Trench—No. ................2_• Width_-_-_--'--_____-___- Total Length_-_--__•_--_._-_---. Total.leaching area-..:i_:. ----------sq. ft. k Seepage Pit No_____________________ Dianiiner�..._.....k---------- Depth below inlet.................... Total.leaching area............_,_ ----sq. It. 1 Z Other Distribution box ( ) '° Dosing tank a Percolation Test Results Performed=-bY--------"................................................................. Date-----•----------------'"------------------- Test Pit No. 1................minutes per inch Depth of Test-Pit----_________-___.-- Depth to ground water...----_-__-'_�-_._.. f14 Test Pit No. 2................minutes per inch-7D'epth of Test Pit.................... Depth to ground water-------------------- ,.. � =- -: ;: -----------------------------------------------••--------------•----------------------------------- -. DDescription of Soil------------------------------------------------------•••-••-•••-•--"......------......:--•••---•-- ----------•----•-------------------------------------------------- -------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- --------------- V Natu e epairs Alterat• ns—A sw en applicable._... .__ _ .�� �....................... --------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli 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 bqeff ssued bythe�bor h ied. -- -- - ---- --ai ..................� . Date Application Approved B Date Application Disapproved for the following reasons:..................................................................... ................... .................. --•-•.................•--•--•----•--•-------••----.....--- -•---•-----•--•---•------...-----•---------'------•-----•---........_.....---•••......-------• - ---- ate Permit No................. Issued._._... .. ....... e THE COMMONWEALTH,,gF>,MASS.ACHUSETTS BOARD F HEALTH,,,,_....... .. ......O F...... . .. . .. � .. .. .. ... .. ..........:...... .-...,� • .>:t. ~fix K. . �rrtifirtttr oaf f�>arit�li�tnrr THIS VCIFY at the I dividua ewa isposal stem nstructed -) o`r�Repaired y '.r//tJ --•----•-•- --•-- __ ..... ......... .. .. ..___I-- ----•--•-•~ •-------Ins a ., has be n installed in accordance with the provisions of Articl�,�Y �The State Sanitary Code s des ibed in the application for Disposal Works Construction Permit No.,___._ .................... dated..... ._f4�. ...t"' :.. ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED-AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE -•-•----•-----------•---•--•----•-•---...... Inspector.................................................................................... p THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALILJ ....... f4.:(j0.-..!lp.......OF....... ..: No.... . ........... FEE.. ............... Bi poiial vr1W Ql a trurti n pr , t Permission is hereb grant. .... _ '_._ ... to Con r t ( ) or epair ( Individ Se ge isposal ys m at No. '!y�*------ ----------� .�--• s � � ��f Street as shown on the application for Disposal Works Construction it N ---==-- ----- Dated----- $ B d oar o Healt '°i�"'✓._.-.. / s s ` FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS