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HomeMy WebLinkAbout0177 SCHOOL STREET - Health (2) 177 School.Street Marstons Millss / 1 r i � �I Commonwealth of Massachusetts (A- ©I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 School Street Property Address Derek Gavin Owner Owner's Name information is required for every Marstons Mills Ma. 02648 07/08/2016 page. City/Town State Zip Code Date of Inspection F Inspection results must be submitted on this form. Inspection forms may not be altered in way. Please see an Y e completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere keY y the return Name of Inspector Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address Ma— shpee Ma. 02649 City/Town State Zip Code 508-280-3356, S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 07/08/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 V/ L �9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,•'' 177 School Street Property Address Derek Gavin Owner Owner's Name information is Marstons Mills required for every Ma. 02648 07/08/2016 page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria hot evaluated are indicated below. Comments: This home has a H-10 1000 gallon septic tank an H-10 D-Box and two pre cast leaching pits B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 f Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 177 School Street Property Address Derek Gavin Owner Owner's Name information is Marstons Mills required for every Ma. 02648 07/08/2016 page. Cityrrown State Zip Code Date of Inspection I B. Certification cont. ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 177 School Street Property Address Derek Gavin Owner Owner's Name information is Marstons Mills required for every Ma. 02648 07/08/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioningin that a manner at protects the public health, safety and environment: p ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 School Street Property Address Derek Gavin Owner Owner's Name information is required for every Marstons Mills Ma. 02648 07/08/2016 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate i regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 177 School-Street Property Address Derek Gavin Owner Owner's Name information is required for Marstons Mills q every Ma. 02648 07/08/2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Z Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 School Street Property Address Derek Gavin Owner Owner's Name information is Marstons Mills required for every Ma. 02648 07/08/2016 page. citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does re sidence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes El No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 177 School Street Property Address Derek Gavin Owner Owner's Name information is required for every Marstons Mills Ma. 02648 07/08/2016 page. Cityrrown State Zip Code Date of Inspection 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 ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 III f - Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , ' 177 School Street Property Address Derek Gavin Owner Owner's Name information equir for is every Marstons Mills required for eve Ma. 02648 07/08/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 21"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 12"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: standard H-10 1000 gallon Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 177 School Street Property Address Derek Gavin Owner Owner's Name information is required for every Marstons Mills Ma. 02648 07/08/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle apx. 35" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle apx. 5" Distance from bottom of scum to bottom of outlet tee or baffle apx. 12" How were dimensions determined? sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept. has a list of local pumping co. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 School Street Property Address Derek Gavin Owner Owner's Name information is Marstons Mills required for every Ma. 02648 07/08/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 177 School Street Property Address Derek Gavin Owner Owner's Name information is MarstOns Mills required for every Ma. 02648 07/08/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box present( must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection there no signs of solids carryover or evidence of past hydraulic failure Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 177 School Street Property Address Derek Gavin Owner Owner's Name information is required for every Marstons Mills Ma. 02648 07/08/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two ❑ 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.): At the time of the inspection there were no signs of past hydraulic failure 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 t5ins•3/13 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 177 School Street Property Address Derek Gavin Owner Owner's Name information is required for every Marstons Mills Ma. 02648 07/08/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): I t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 177 School Street Property Address Derek Gavin Owner Owner's Name information is required for every Marstons Mills Ma. 02648 07/08/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage'Disposal System•Page 15 of 17 f 70WN OF BARNSTABL.E LACAnON-J-17 Sc40,2.! 94- SOWAM JJSTajt WS NAME&PLLONE No. T Q /�tdlQ ilaJ SEMC'PANIC CAPAQW 9 U 44 --- NO.AI:BEAL3o0ALS— — — -- VVIM OR Aal NFA SAW* (4A N,a PIIpA►3E: .2�_1�CpAJ�LtAC LaA3A: bl4xigotuea Afdjststsid Gcc�aa4a�atar�Abk Av,4 9f i�se�igg'PAc�Itcy : /� .L � Foy*WSW.SWOY W,40MWJAXW$ftWtyWAPYW43eMSJt ----- Aus a�dthaa 2a ka of kgb*ttts*ty) �`J Feet WAOMW And ing F.ssilitY(WARY suet ands exist ---- mloap 39 fmcof kwkq(w4ty) _ �e/� Feet E,�t�p�ist�by E F 4e b R L: 4 = 3-;L f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 177 School Street Property Address Derek Gavin Owner Owner's Name information is required for every Marstons Mills Ma. 02648 07/08/2016 page. Cltyrrown State Zip Code Date of In spection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show five plus feet of seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 177 School Street Property Address Derek Gavin Owner Owner's Name information is required for every Marstons Mills Ma. 02648 07/08/2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file reel V Hz0 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i _ I t o o� s�L� a.- .a 6� 1 L�VI 23 �� 1J Lyo 00 o� -'`730-2-5 AsBuilt Page 1 of 2 n /TOWN OF BARNSTABLE LOCATION I �� hota C S� SEWAGE# VILLAGE _ [ 1 fS ASSESSOR'S MAP&LOT OyZ-d<i INSTALLER'S NAME&PHONE NO. Il' &k M) SEPTIC TANK CAPACITY i S a t> S"t Z LEACHING FACILITY: (size) NO.OF BEDROOMS_ BUILDER OR OWNER NA G i. Sy ry f Gt1 PERMITDATE: DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility p' Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by G C� r- C..- = 3 z c.G http://issgl2/intranet/propdata/,prebuilt.aspx?mappar=046012&seq=1 7/5/2016 COMMONWEALTH OF MASSACH LSETTS EXECUTIVE OFFICE OF EIv'VIRO1\-Ik1E--\7T-A-L AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION e� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A /'� / CERTIFICATION .VJ 7/7 Property Address: / 2 / �G h 00 �7'- i Owner's Name: J tV yl i'Gti, Owner's Address: /0 8S ,fG i✓�i h a h qG c`,f (%lest hK.,ras a e Oa 6 6 a? Date of Inspection: 0 Name of Inspector: lease print)?'OQYK Company Name: — 1/i 0"%4=G IV Mailing Address: y OX I . © ram• �L!{.1 0 Telephone Number: 0K CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: o� Date: S 6 p The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office ofthe DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, authority. and the approving Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 t Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLLTT_ARY ASSESS-TENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-11 PART A CERTIFICATION(continued) Property Address: / / �G 400/ .� Owner: (,la q N a(r Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. SY3tem Passes: I have not found any information which indicates that any of the failure criteria described in 310 C_-MMR 15.303 or in 310 CNM 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.,� System Conditionally Passes: /V One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the followina statements. If"not determined''please explain. ` The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound;not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(�iith approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is Ieveled or replaced NTD explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The s.-siem iti? pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Tit1. G 'nennrtinn t e i rnnn L Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS'vfE\TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A n /CERTIFICATION(continued) Property Address: / SC[n oo/40 Owner: .SG G, Vt G a a Date of Inspection: (, p 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 CIvIR 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 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 crater supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: T,tlo S tncro Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �— a Owner: G L✓q L, a v+q Date of Inspection: S L o D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for an 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 around or surface waters due to an overloaded or :logged SAS or cesspool /Static liquid level in the distribution box above outlet invert due to an overloaded or cloaQed SAS or �eesspool " L Liquid depth in cesspool is less than 6"below invert or available volume is less than'.day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number tunes pumped Katy 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 ,hater supply. c/QAy portion of a cesspool or privy is within a Zone 1 of a public well. _ �.n"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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria /n are triggered.A copy of the analysis must be attached to this form.] 14 N (Yes/No) The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15.000 gPd• You must indicate either"yes"or"no"to each of the following: Xyes owing criteria apply to large systems in addition to the criteria above) ` 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—hVIOA)or a map-Dee 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 ans�Bred "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 wi h 0 C1IR 15.304.The system owner should contact the appropriate regional office of the Department. ritin i Tncncntinn T-`nr.v. �/1:/7nnn d Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSINIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: l SG AVOI J57- G�S ✓t /Jff Od6Srd Owner: ��r,✓� ✓t�.6- h i Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant;or Board of Health v/Were any of the system components pumped out in the previous two weeks ✓ Has the system received normal flows in the previous two week period? —'--Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as .\'/A) Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? _ Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes n� Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J "^itlo f Tnenurtinn ❑nrir �,/7[/lnnn Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �y SYSTEM INFORMATION Property Address: / Se Aoo/ f�4 a r� vt S i f� /ili Oa 6 Owner: Gr WA Date of Inspection: C1019 RESIDENTIAL FLOW CONDITIONS V'i r-7 Number of bedrooms(design): 41" Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x=of bedrooms): T�� Number of current residents: O Does residence have a garbage grinder(yes or no): /lam Is laundry on a separate sewage system(,Yes or no):IV4 [if yes separate inspection required] Laundry system inspected(yes or no): /�0 Seasonal use:(yes or no): 0 Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes orn Last date of occupancy: N COIND IERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgtetc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORIMATION Pumping Records Source of information: O�00 6— c9 try✓. Was system pumped as part of the inspection(yes or no):/LtJ If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: T!!Ypf s'Y S T E 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 contrac-(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components, date installed(ifImo. )and source of information: Were sewage odors detected when arriving at the site(yes or no): lf�V Tit10 rnenarti _ i i„ f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION(continued) Property Address: Owner: Sc4 w4:2 a✓i r Date of Inspection: 6 O BUILDING SEWER(locate on site plan) Depth below grade:_/_ Materials of construction: st iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): c/ SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Y //0 Dimensions: /` Sludge depth: 02 1� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0Z2ss / " �, y Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bo f outlet ee or baffle: How were dimensions determined: Comments.(on pumping recommendations,inlet an utlet tee or baffle condition, structural integrity; liquid levels as lated to outlet invert, evidence Tea age,etc): ✓� i r, h!7 neede c m it 7�/✓`''�, TG'''�Li/ Gvl GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition.. structural integrity. liquid'evels as related to outlet invert, evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / // se ADO S�-- GY'T ONj t� ,-�4 Dot 6 Owner: G Wa c,Wq , • Date of Inspection: V4102 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid Ievel above outlet invert: 0 0/0I ? Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakaae into or o t of box. etc.): .�o Ile, li'o So/, /din PUMP CHAMBER:A (kocate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Tit)u �'Tncncrtir�n �nrm �It ci�rann 4 • Page 9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Gl W ti AtAtiri' Date of Inspection: 6 O SOIL,ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Typ x leaching pits,number: j21-2 — Caf leaching chambers,number: leaching galleries,number: f S f p h 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.): f�,0 Cji N s4C a-7 L, ti-e ��� '✓Q�p v i N�� CESSPOOLS: /V (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY: A (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.): Title � Tnc+�crtinn L'...-.,� C/t c�lnnn o Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUTNT ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C A'V1 Owner: G H Date of Inspection: s' 6 O SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. � G c�-39 — (�'3 -916 33 or .i 1 `r T410 TTC 1P fl 1y > n.m 411{/7nnn l n Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / / -S�AOpt S7� a.-r T 'I • 1 Dot 6 07 Owner: w u y a v►ti ­r Date of Inspection: , 6 0 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water S3 feet r0 Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Necked with local Board of Health-explain: Z_14/¢/,c Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: o ✓h 7C �e Qj>4 6'& O 4"— /e. p �i /j/ q � S. /s �O`Gt" /O✓t ��e� T;tl. < Tn ennrtinn �nrm G/1 /'lnnn 17 FORM30 &w Hons&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD U HE H Al MY T WN Z E ` PARTMENT ADDRESS G„M S 0y`eW —7 +TEPHO N Address I r� Occupant upa Floor Apartment No. _No. of Occupants L �-� No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming___9 units No.Stories Name and address©ov�nr r " Mxe. zt�AL Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ` ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen:Sanitation: Dampness: Stairs: 0.9 Lighting: 444 Ott 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 U Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: tkeks, F ues,Vents eties: 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 Locks on Doors: ONE OR MORE OF THE VIOLATION 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 UNDE THE PAINS AND PENALTIES�PE J , ." INSPECTOR E 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 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 ana,therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. 0 An of the following conditions which remain uncorrected for period of five or more days following the notice to or ( ) Y 9 P Y 9 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. R b FORM30 &w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE 4 H I Y OWN W T c -PARTMENT 0 ADDRESS ��M svBysew T�I.EPHON <71 Address — Occupan Floor Apartment N�No. No.of Occupants i t L Z No.of Habitable Rooms ing Rooms No.dwelling or rooming units .Stories Name and address of ov ner 1�s Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: T 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: U .r- r 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 t Bedroom 1 1 Bedroom 2 pUf Bedroom 3 t v Bedroom 4 Hot Water Facil. `Sup.Ten.,Gas, Oil, Elect.: Stacks, F ues,Vents, feties: 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 1 Locks on Doors: ONE OR MORE OF THE VIOLATION 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 UNDE THE PAINS AND PENAL TIO P_EM " �C INSPECTOR TITLE A:,M. DATE TIME ` A.M. THE NEXT SCHEDULED REINSPECTION s 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 ana,therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates'[cost$30.00 for 4.years)..A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does*not give you permission to operate.).. Business Certificates are available at the Town Clerk's Office, 1"° FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) tl@�78 umwz.rawa„ GATE- �Z L O 1 Fill in please: .. i9:.t�Y' t t r r jri�pr t f •. s � .t APPLICANTS YOUR NAME: ANfoNloBIZ IT BUSINESC YOUR HOME ADDRESS: I+I1 Sc Wr_ Ss � k �� 1� � -1�1-2(Oq-1°►�� . MA-RSfbNS MILLS MA 0 bi-I 96. TELEPHONE # Home Telephone Number NAME OF NEW BUSINESS T" T7Lwa N TYPE OF BUSINESS CoNsI RycTto►J T10 try IS THIS A HOME OCCUPATION?. YES NO .: . Have you been given approval from the build.in'g division'' YES NO ADDRESS OF BUSINESS_ 1-1-1 SCPocoL ST i MkQSiONS MI L- S 02(ozl MAP/PARCEL NUMBER Z When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form.is intended to assist you in obtaining the information you May need. You MUST GO TO 20.0 Main St. - [corner of Yarmouth Rd. & Main Street):to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authprized Signature* COMMENTS: 2. BOARD OF HEALTH This individual ha info Vedf the rmit re uirements that pertain to this type of business. Aut rized nature** , COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of.business. Authorized Signature* COMMENTS: ,Hazardous Materials Inventory Sheet Checklist ��I66 �-t)ate L___Physical Street Address-Check database to ensure it exists A:::::-Working Phone Number �r Actual Amounts-(le.gas being used to fuel machines,thinner to clean brushes all count as hazardous materials) }__Zt,L�Storage Information-location of storage,how long is storage for? If none,note.that. tsposal Information-where and who?If none,note that. Applicant Signature-understand what Is listed and noted L41v Staff Initial-any questions,know who to ask Vehicle Washing/Rinsing? -provide a vehicle washing policy and explain it-note that it was given _Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussrri with ttio.., Date: 103//,?—/ca00 zz, TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY � NAME OF BUSINESS: 14--E FLOOR M"N BUSINESS LOCATION: 111 Sc4+001. Sr% - MA-a<1_00S M ILI s Mom' INVENTORY MAILING ADDRESS:01 SCIro00L S` HA aS_1aNS MILLS MA-- 02(04 8 TOTAL AMOUNT: TELEPHONE NUMBER: -11�- IT61 CONTACT PERSON: NN-roNic>. _Ea%�o EMERGENCY CONTACT TELEPHONE NUMBER: 26� -I g `b� MSDS ON SITE? TYPE OF BUSINESS: C *>W L"roro INFORMATION/RECOMMENDATIONS: DbNo-r Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Propuct: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, ,. storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following oI jexhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive -V kUt v�GD NEW USED Cesspool cleaners— Automatic transmission fluid Disinfectants Engine-and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants ��C� ►�,+c Motor Oils Pesticides ( ►� �/� �( NEW USED (insecticides, herbicides, ro enticides) I Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED `v" Misc. petroleum products: grease, Photochemicals (Developer) Ib� lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Xtq�gts, varnishes, stains, dyes Other chlorinated hydrocarbons, X ,Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes ma be t oxA or hazardous 1please list): Laundry soil & stain removers LUA I (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS __ _ --- I---�- --- --_ - - -- - - - � � � r ����� � � ������ . � _ �� ��fit' I � ���� � ��=� �, � � � i � �� J .- _. I j � TOWN OF BARNSTABLE, MASSACHUSETTS BUILLANU FLHI M I A-046�-Uli DATE Julle 6 94 pERMTIT NO. liti �v�v`t APPLICANT SEaaide Construction ADDRESS Box tIlTT1.s, �A HIC 116.126 (NO.) (STREET) (CONTR'S LICENSE) PERMIT TO Add to dwelling (_) STORY Single family dwelling NNUMBER OF NG UNITS 1 _ (TYPE OF IMPROVEMENT) NO. IPROPOSED USE) AT (LOCATION) 177 School Street, Malrst(.ITIS lVlill•> ZONING CT kE DISTR (N0.) (STREET) BETWEEN AND (CROSS STREET) (CROSS STREET) LOT SUBDIVISION LOT-BLOCK-SIZE BUILDING IS TO BE FT. WIDE BY FT, LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION TO TYPE USE GROUP R BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS: Sewage #94-290 AREA OR Add 672 Sq. ft. 35,000 PERMIT 50.00 VOLUME ESTIMATED COST $ FEE (CUBIC/SQUARE FEET) OWNER Paul & Bandra Sawayaflagin , ADDRESS' 7 SchoolJtreet, arstons 1 _ s# BUILDING DEPTBY t ----•- THIS P4RMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP- PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND 1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL I MEMBE'RS(READY TO LATH). FINAL INSPECTION HAS BEEN MADE. 3. FINAL INSPECTION BEFORE OCC V•PANC Y. POST THIS CARD SO IT IS VISIBLE FROM STREET EUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 171 F/- /L 41emr HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT BOAjBrTH Fy-,L 01MR SITE PLAN REVIEW APPROVAL j l S MAP WORK SHALL NOT PROCEED UNTIL THE INSPE P E RM I T W!L L B E C 0 M E N U L L)LAW 6 V 01 D P 10 IN INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES F WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTION. I PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION.