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HomeMy WebLinkAbout0709 WAKEBY ROAD - Health 709 Wakeby:Road .{ I_ Marstons Mills cn ��t�r � ��P�',�� �� ��� �,�x=�6i7- �83 - � 7�0 rV709 Wakeby Road Marston s Mills A = U8 025001 # �_ __.- a No, 4210 1/3 YEL ----� p(@n nMf7 a v P EELT 10% s ASSESU, 'S MAP No. ��j PARCEL t� Gz� try Z5 r Avg O� lLO- CATION SEWAGE PERMIT NQ. VILLAGE \INSTA LLER'S NAME �� ADDRESS S®A Q- 55 ONUILDER OR OWNER «i DATE PERMIT ISSUED 3 a.;g r°�4F e.. .. t DATE COMPLIANCE ISSUED 94 ✓ �.r-n.��..r. 1 �'� .� Q it �'` L�"� 5 �. (�rlCLk- IR�C�4u%gym MA, IZA, lT ,e%✓ irc�-��y A�ic m,�,Ti oS LuAarar�f AGifji�JlS�i ;i✓F �N D P7c,- u�z� fi k,SJd�ZL 'S I(7D yc�s, off` SOIL, SUP6/2VlSE ���f� �c�� , s��.�. ,z� Tt�,- �� ���1 ��ax �6��— ��3 � ( °l70 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $40.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO according to M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. DATE Fill in please: / APPLICANT'S YOUR NAME/CORPORATE NAME PA��L S L e�wN cc c e A,-,//,'P ap4 sy6r 1- BUSINESS YOUR HOME ADDRESS: 709 VVA&tdy 2U4c' l-7cn,roA. I-t;il_r / ,,* ozdyy 7 711,)92 syi 2 TELEPHONE # Home Telephone Number 7 7`/ J 9:1 ,S 9/2- NAME OF NEW BUSINESS_ PA,Y '5 L t w.v Car'a Have you been given approval from the building diva,p ion? YES NO ADDRESS OF BUSINESS 709 0.-1 w MAP/PARCEL NUMBER L,^k d 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 200 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 CO SSI ER'S OFFICE This indivi ual a e edof any permit requirements that pertain to this type of business. MUST COMPLY WITH HOME OCCUPATION riz Si rw-ei .* RULES AND REGULATIONS. FAILURE TO risoc -t elti ON' ""0'.. lne n s 2. BOARD O HEALTH This individual has bee or of the permit requirements that pertain to this type of business. MUST ,OMPLY WITH ALL HAZARDOUS MATERIALS REGULATin;_iS Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSI AUTHORITY) This individual has ftWn inf r e o the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: � r � l TOWN OF BARNSTABLE Date: 0 TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: gf/ s L a Ida ccr- BUSINESS LOCATION: 709 tdgArjje /1o11/ INVENTORY MAILING ADDRESS: 705 LVAR94 y 904-cl TOTAL AMOUNT: TELEPHONE NUMBER: _ _ 771 J q)- S5/) CONTACT PERSON: If//1'/' A S->✓*_ EMERGENCY CONTACT TELEPHONE NUMBER: So k Z 29 j MSDS ON SITE? TYPE OF BUSINESS: Law w 140w,'NS INFORMATION/RECOMMENDATIONS: ���sT LawN Hou,r'w5 � Tr,'m Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material 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 products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) 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 Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes -TuSt KoW,'w� Lawws ,uo Laundry soil &stain removers (including bleach) STura„fe y F C/cr, J uS Spot removers &cleaning fluids (dry cleaners) �iGS �',, Mo e,,erS Other cleaning solvents Bug and tar removers Windshield wash c� WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Sig ture Staff's Initials LX Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22F N 0 page. CitylTown State Zip Code Date ofol'nipetxion - Inspection results must be submitted on this form. Inspection forms may no 6e altereo�n air way.Please see completeness checklist at the end of the form. "`= Important:When I' - �°filling out forms A. General Information on the computer, use only the tab 1. Inspector. �-n key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Company Address Centerville Ma 02632 CityrTown State Zip Code 774-248-4850 SI 4522 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 2/22/2010 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•09108 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 709 Wakeby Rd. Property Address Clyde& Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityrfown State Zip Code Date of Inspection B. Certifications (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 WakebY Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 WakebY Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityrrown 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. ❑ Z 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 regional office of the Department. t5ins•09108 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 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 340 gpd provided t5ins•09f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of(Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner owner's Name information is Marstons Mills Ma 02648 2/22/2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2008=296 gpd 2009=222 gpd Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Tifle 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-D9108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. I` Property Address I Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. CityrFown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 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: New system installed 2005 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: .5 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: 1000 gallons Sludge depth: 10" t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 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 3' Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" 991 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank needs to be cleaned soon and then again every 2 years as maintenance. Water level was at bottom of outlet invert. Tank was structurally sound and not leaking. outlet tee intact and in good condition. 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Citylrown 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 ❑ 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•09/08 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 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owners Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Water level in d-box was at bottom of both outlets. Water was evenly distributed with speed levelers. No sign of past hydraulic overloading. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Soil and stone were found to be unsaturated. No lush vegetation. No signs of 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 C Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cltyrrown 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 r a-AJ- LOP 166e 3 t 3 _i: 7 S R .y S > 15ins•09108 Title 6 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 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. 12+ 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: 6/23/2005 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: Design plan on file at Town of Barnstable Board of Health shows no groundwater was encountered 2 144". Plan shows a seperation of 5+feet between bottom of s.a.s. and adjusted high groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owners Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityrrown 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,..' 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 � page. City[Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I use only the tab 1. Inspector. key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. 01--�� S.M.Jones Title V Septic Inspection "ICI Company Name 74 Beldan Ln. Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 SI 4522 Telephone Number License Number B. Certification I certify that l have personally inspected the sewage disposal system at this address and that;Ihe o information reported below is true, accurate and complete as of the time of the inspection. Tt a inspig&ion was performed based on my training and experience in the proper function and maintenance o1 on sewage"disposal systems. 1 am a DEP approved system inspector-pursuant to.Section 1#'140 Title 5(310 CMR 16.000).The system: b ® Passes ❑ Conditionally Passes ❑ Fails ' ❑ Needs Further Evaluation by the Local Approving Authority M 2/22/2010 Inspector's Signature `-" Date The system inspector shall submit 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. 2-1 t5ins•09M8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page t of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's(dame information is required for every Marstons Mills Ma 02648 2/22/2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order.to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1ub)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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Ownets Name information is required for every Marstons Mills Ma 02648 2/22/2010 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 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. 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 El ® or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) Y 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 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 w ❑ ❑ 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•09/08 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 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): pro gpd rovided t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry- Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2008=296 gpd 2009=222 gpd Sump pump? ❑ Yes ® No Last date of occupancy: current Date CommerciaUlndustrial 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments r 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. City/town 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•09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is Marstons Mills Ma 02648 2/22/2010 required for every 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: New system installed 2005 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 5 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: 1000 gallons Sludge depth: 10" t5ins•09MB 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 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 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 3' Scum thickness 3„ Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 911 How were dimensions determined? Opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank needs to be cleaned soon and then again every 2 years as maintenance. Water level was at bottom of outlet invert. Tank was structurally sound and not leaking. outlet tee intact and in good condition. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal . ❑ fiberglass ❑ polyethylene ❑ other(explain): l 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's(dame information is required for every Marstons Mills Ma 02648 2/22/2010 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 ❑ 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•09/08 Title 5 Official Inspection Fort: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 r 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is Marstons Mills Ma 02648 2/22/2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Water level in d-box was at bottom of both outlets.Water was evenly distributed with speed levelers. No sign of past hydraulic overloading. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityfrown State Zip-Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number. 2 ❑ 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.): Soil and stone were found to be unsaturated. No lush vegetation. No signs of 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-09/08 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 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. Cityfrown 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.): t5ins•09/08 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 r� 709 Wakeby Rd. Property Address Clyde &Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. City/town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately R-GAI� J� KoJS� P� 3 6 UU I i v a , TAN✓- ,yam, :, 3 A a7 y S 13 • a- 2d �} -3= (oa' B3= 97 S_ A -14: Q_ y s`3 A -S: S D t5ins•09/08 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 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/22/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. 12+ 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: 6/23/2005 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: Design plan on file at Town of Barnstable Board of Health shows no groundwater was encountered 2 144". Plan shows a seperation of 5+feet between bottom of s.a.s. and adjusted high groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17. Commonwealth of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 709 Wakeby Rd. Property Address Clyde&Suzanne Perry Owner Owner's flame information is required for every Marstons Mills Ma 02648 2/22/2010 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 l t5ins-09/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 —• i TOWN OF BARNSTABLE V LOCATION,_20q Wa Kc�ca al ' SEWAGE # DOS 31 Z t YII:LAGE CD.�or,5 ('rl: 1 IS ASSESSOR'S MAP & LOT 2 - PS-Ol J-NSTALLER'S NAME&PHONE NO. RC,Scr-i G i Kbu SEPTIC TANK CAPACITY I Da0 o a i Ior� LEACHING FACILITY: (type.) ehacntS (size) COY X- 13 A of NO. OF BEDROOMS 3 BUILDER OR OWNER.� Qr'�h��a�tty�S PERMPTDATE: G 3oY _ -uMPL GATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility *Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching;Facility(If any wetlands exist within'300 feet of leaching facility) Feet Furnished by L b� A i = q6vT,T �. AZ _ 1/9 _67 - ,3,P A3 tJwo,�►�9 ,03 : q$ b t s A Ay s? .Bq AS O ' o No. 5 / Fee ®C.✓ THE COMMONWEALTH OF MASSACHUS9TTS _, Entered in computer: Yes PUBLIC HEALTH'DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Miopooal *potem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade Abandon( ) O Complete System O Individual Components ' J Location Address or Lot No. 161 uI 4 kQ by R D Owner's Name,Address and Tel.No. /�lctrs+ons M1116 ;AA peJDbl_ Lreve �ptmo�th Assessor's Map/Parcel 1 m,p h 19, an Rd� E AOP Va Marcel ZS -oI 0 - S L4 p. q U20 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. lobert (4i1foy-13tG ExcaVa}i -on Oclvicl Masan Environmental �sl9r I Li Tea berry LnTore5tdQle MA- 1-1-17-06 E• Sg du ndW i 509-933- 2-1-17 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ito gallons per day. Calculated daily flow 3 3 D -gallons. Plan Date (c 2.3 D Number of sheets Z Revision Date Title t C �' SGWQ C �14r7 170 P-d A_ .A111S Size of Septic Tank DOD &4ci I Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued 4y4hkBoard of Health. Signe O Date 3 0 1 0� Application Approved by Date �8 Application Disapproved for the following reasons Permit No. f2 73&9-- Date Issued No. Fee 1 THE COMMONWEALTH OF MASSACHUST Entered in computer: Yes _:VIPUBLIC HEtAt1 Fi`DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppfication for ;Migpooaf 6peUm Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade(VI)Abandon( ) O Complete System El Individual Components Location Address or Lot No. `� 9 �/� Q�� 1 17 Owner's Name,Ad ress and Tel.No. - /A cirStpns KIIS AAA (Debbie e_1re\ie. �01�nUUt�l Assessor's Map/Parcel �1 ci p 2 "��� e I Z 5 - U I 1 S U p U'1�.% U Ud i E Installer's Name,Address,and Te.No. Designer's Name,Address and Tel.No. lzobert Gib-Foy- - 2EXCC1VCX+ion O.ovid mo-bon Envir'onment0lI)e519, 05 , I ILA Teo bercy LnTore5td41e, MA 1117-06 ' C, Sdr-\dwlfcF 5 0 9- 833- 21-17 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) - Other 'Type of Building 1 No.of Persons Showers( ) Cafeteria( :) � Other Fixtures Design Flow Ito gallons per day. Calculated daily flow -3 3 D gallons. Plan Date 0 23 10 5 Number of sheets O-- Revision Date Title S I e~ T S e w riq f, n 7Uq (,t)r+kP f�)g (2C Size of Septic Tank U DU 14 Type of S.A.S. Description of Soil � P 'Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ..ram Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a,Certifi- cate of Compliance has been issued Board of Health. Signe nl i, Date 3 0 U + Application Approved by Date 3d 5 Application Disapproved for the following reasons > ror Permit No. 55 3��L Date Issued 36 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by 'BT GE 67 i (0\/ at `7 0 9 \N n kt._bti -Rd . M Q r51 on S kW l S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer I?o b e r I C-t � � 1C0 �/ Designer Ibck � Ci 5 o n The issuance of this pe t Zhll of be construed as a guarantee t at the syste it°(I unct o as designed. Date � 7 Inspector __..- No. G-I�� � ------------------------- 3�a-� Fee !✓0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Digpoof *pgtem (Conn;truction Permit Permission is hereby granted to Construct( )Repair( ,,)UAUpgrade(,v )Aban on( ) �,A System located at D Y�IGt keh�/ �cl /v1Cl ("S f"D f1S V �`-� .I"`A and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conddtian Provided: Construction musk be completed within three years of the date of t� i to 1301 � Date: Approved by 9/16/03 Notice: This Form Is To Be Used For the repair Of Failed Septic Systems Only r PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM hereby certify that the engineered plan signed by me dated concerning the property located at 709 WD KF.&L( meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation testss at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information), 9d,oo -n B) G.W.Elevation +adjustment for high G.W. S DACE BETWEEN A and B � z� SIG DATE: NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q ASepticipercexemp.doc COMPLETETHIS SE&TION ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X / 3 Agent , ■ Print your name and address on the reverse rt9 , ❑Addressee so that we can return the card to you. B. Receiv al�p■ Attach this card to the back of the mailpiece, Y Pri d Name) C. Da of De ery or on the front if space permits. D. Is delivery address different from item 1. e 1. Article Addressed to: If YES,enter'delivery address below: ❑ No M���&Mrs T;n-tothy Greve 18 Amphibian Road East Falmouth, MA 02536 3. Service Type ❑Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number - - _ .-- I (Transfer from service label) ? 01 032�00_ 0 3 669. 5 5.8 5 4_ PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS, Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • PIGIE;LlC HEALTH DIVI SION 'TOWN OF BARNSTABLE 200 MAIN STREET HYANN S, MA; SACPIUSETTS. 02601. � I I fill 11"ll II ■ . .,� � nI^' r� �'s � ..r--tom,. x Ln Ln u7 Postage $ O S Ln Certified Fee i a� n3 Q� ®Postmark Return Receipt Fee N Here (Q (TI (Endorsement Required) 0 ! Cj Restricted Delivery Fee N (Endorsement Required) (1� .7 M Total Postage&Fees $ru M Sent To C3 a No"or PO Box No. -------- � t 1�_--- - c-�--___-- -------------- M Ciry,State,ZIP + � 6 Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece o A signature upon delivery e A record of delivery kept by the Postal Service for two years Important Reminders: 12 Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. o Certified Mail is not available for any class of international mail. ti NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Retum Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811),to the article and add applicable postage to cover the fee.Endorse mailpiece`Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is required. I'll I o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix iabel with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry," PS Form 3800,January 2001 (Reverse) 102595-01-M-1049 f CF THE T Town of Barnstable 9QB„� , ` Regulatory Services pA i639. �e� Thomas F. Geiler,Director tFOMA�a Public Health Division Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 19, 2005 Mr&Mrs Timothy Greve 18 Amphibian Road East Falmouth, MA 02536 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V.. The septic system owned by you located at 709 Wakeby Road, Marstons Mills, MA was inspected on May 10`t', 2005 by rd, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has failed the guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: Leaching pit was full of sewage,to the top. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HE TH DEPARTMENT COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �e TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 709 Wakeby Road ' Marstons Mills MA 02648 Owner's Name: Tim&Debbie Greve Owner's Address: 18 Amphibian Road East Falmouth MA 02536101 Date of Inspection: May 10,2005 Job#05-118 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. N) Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 w co CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inforination 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: 1n1OF MgSS ' Passes y> Conditionally Passes ~~ ••' tiG Needs Further Evaluation by the Local Approving Authority a P 1C m Fa i z 'C LL Inspector's Si nature: P g . Date: 5/10/05 � SIN The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of He a�it�i� t�t������ DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching pit full to top. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 709 Wakeby Road,Marstons Mills Owner: Tim&Debbie Greve Date of Inspection: May 10,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: T41.C Tnenarfinn Fnrm lil ai�nnn 2 Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 709 Wakeby Road,Marstons Mills Owner: Tim&Debbie Greve Date of Inspection: May 10,2005 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 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 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: TWA G Tna.+urtinn Fnrrn rii;i,)Ann 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 709 Wakeby Road,Marstons Mills Owner: Tim&Debbie Greve Date of Inspection: May 10,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X— _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped —X Any portion of the SAS,cesspool or privy is below high ground water elevation. _X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. X_ 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 are triggered.A copy of the analysis must be attached to this form.] _Yes_(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: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Titles G Tncnartinn vnrm Ail;i,)nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 709 Wakeby Road,Marstons Mills Owner: Tim&Debbie Greve Date of Inspection: May 10,2005 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks X_ Has the system received normal flows in the previous two week period? _ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ 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)] Ti+1A G T"cnar+inn 17^r 4/1 ai)nnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 709 Wakeby Road,Marstons Mills Owner: Tim&Debbie Greve Date of Inspection: May 10,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)):. N/A well water Sump pump(yes or no): No Last date of occupancy: Two weeks prior to inspection. COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: - Was system pumped as part of the inspection(yes or no): 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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date:7/8/86 Were sewage odors detected when arriving at the site(yes or no): No Titlo i Tnonontinn 17nrm 9/1,qnnnn 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 709 Wakeby Road,Marstons Mills Owner: Tim&Debbie Greve Date of Inspection: May 10,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 6" Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: - Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 3" Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide—1000 gal. Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: - Scum thickness: 7" Distance from top of scum to top of outlet tee or baffle: - Distance from bottom of scum to bottom of outlet tee or baffle:- How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Baffle decayed and falling off,needs to be replaced when new leaching system installed Liquid level at bottom of outlet Dive. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal— fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Titla i Tncnartinn Rnrm f/I c»nnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 709 Wakeby Road,Marstons Mills Owner: Tim&Debbie Greve Date of Inspection: May 10 2005 P Y TIGHT or HOLDING TANK: No (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: XX (if present must be opened) (locate on site plan) 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.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title G Tncnarfinn T7nrm 4/1 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 709 Wakeby Road,Marstons Mills Owner: Tim&Debbie Greve Date of Inspection: May 10,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type —X_leaching pits,number: One 6x6 pit 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.): Liquid level over too of structure with high stains to tou of risers CESSPOOLS: No (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: No (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.): T41a C Tnenantinn T7nrm r,il eiinnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 709 Wakeby Road,Marstons Mills Owner: Tim&Debbie Greve Date of Inspection: May 10,2005 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. Wakeby Road #709 Garage 21 28 77 79 88 90 Title;inenartinn Rnr Aii ai,)nnn 10 Page I 1 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 709 Wakeby Road,Marstons Mills Owner: Tim&Debbie Greve Date of Inspection: May 10,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: A perc test will be performed prior to repair to determine groundwater elevation. T410 S inannrtinn Anr 4/1;/7nnn 11 Town of Barnstable �oFtF+e ra;; Regulatory Services P Thomas F. Geiler,Director • snftNsihsLe, + . 9MAMPublic Health Division f6s.9. . rEpl�A s Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: cLAO 1 D A IS Installer: t- jD Address: .�� Lv� � Q � Address: _ q �27 On �► was issued a permit to install a (d e) (install septic system at I ogsed on a design drawn by (ad s ) A, )i h M/VS C� dated (designer) I certify that the septic system referenced above was installed substa'It''all according to the design, which may include minor approved changes oh as'later r ocation of the distribution box and/or septic tank. 1 Vt* '7 I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local kegulations. Plan revision or certified as-built by designer to follow. �3cz �r (Installer's Signs e) - i• kf. i (I)6si er's Signature) (Affix D igrier's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLLANCE WILL NOT BE ISSUED UNTIL BOTO THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Forth Health Complaints 25-May-05 Time: 9:20:00 AM Date: 4/27/2005 Complaint Number: 18050 Referred To: DAVID STANTON Taken By: SHARON CROCKER Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH Article X Detail: UNSANITARY CONDITIONS. Business Name: Number: 709 Street: WAKEBY RD Village: MARSTONS MILLS Assessors Map_Parcel: Complaint Description: CALLER SAID HOUSE WAS BEING RUN AS A BUSINESS. SODA VENDING TRUCKS WOULD COME BY. NOW APPEARS TO BE VACATED LAST FEW DAYS NO ACTIVITY BY SODA CANS, BOTTLES EVERYWHERE. IT'S A MESS. LOOKS LIKE HAVEN FOR RATS Actions Taken/Results: DS WENT TO SAID LOCATION. DS TOOK AS MANY PHOTOS AS POSSIBLE BEFORE BEING OVERWHELMED BY BUGS, AND HAD TO RETREAT BACK INTO TRUCK. THERE IS A TON OF GARBAGE AND RUBBISH PRESENT AT SAID LOCATION. "NO TRESPASSIN" SIGNS POSTED ALL OVER THE DOORS AND HOUSE. SEVERAL PHOTOS ON FILE. TM MAY CONSULT TOWN ATTORNEYS AS TO NEXT STEP. THIS PROPERTY HAS BEEN TO COURT AND ATTORNEY GENERAL IN PAST, AND WE ARE NOT SURE IF ATTORNEY GENERAL HAS DONE ANYTHING IN THIS CASE. IT APPEARS THE PROPERTY HAS BEEN FORECLOSED PER REGISTRY OF DEEDS WEBSITE. 05/17/2005-DZM followed 1 M , Health Complaints 25-May-05 up and met new owner doing work on site. He has a failed septic system and shall be in to see us. He is working on the inside and outside. New owner is Tim Greeve. Property is also on a private well and is going to connect to town water. DS CONDUCTED A FOLLOW UP INVESTIGATION ON 5/24/05 (DIDN'T KNOW A FOLLOW UP HAD ALREADY BEEN DONE) DS OBSERVED A RED CAVOSSA DUMPSTER FULL ON THE PROPERTY, WITH WORK IN PROGRESS ON CLEANING UP THE PROPERTY. NO TRESPASSIN SIGNS ARE ALL DOWN NOW. Investigation Date: 4/28/2005 Investigation Time: 1:55:00 PM 2 EBY ROADWARSTONS MILLS. 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',..,�: q • 1 * '^ ,U•: M T i`t a '£ 4.'t�' ��" o ".�',� 1" a �.y ,dW 1,p,Si '* I�. �♦y �4 -14 NA , w ti ,, t '? _ ♦ ,u ,..w # p 1, 1,4e.",;bi "!i* , �" `r�'@ -.-. �.� ,�. ♦a� ..� S M �n'�•'-�'� •aa.sa. � `ara.•ee ,� A�� wS "f. � tea, '^�,'" v, i, <;�. �,��'-• � ,': .., ..y.. �' ���� a., '.�,� , -_ !.a �� �' eieayra ,- '.r.^._� `9�..�f �;rS�'°."V'w.mk.,,� �,,=°A.:•r ��' � °„V� �`V p��'�4� MA'S,"�. {� �;. ..,„ � ,:� •w - .,. e�xx�y 1, i, _ "�st�,;T T I ._,,,� �,yr:j� ,� i P, i�� A., 1� a�"�� ��.,���� ; ;'Y �aR x` '''4�'`�♦ s °+Fh ��.,� a. 6 ra N-j. A, J �Y ?:; x ,. `;r"`♦,,. 4' �� .•�wr�..sa�"gh "►aAw ,�:`a`:a• E.„ 'a•' ..d�r� ��#•+',,.�. '4��"°jF 11K1� �,�*��I� � t� \ •�,� "?•S _ a�♦ 0. 1 ra' , •wS'., "...\:' ,a;R, ..a�"'4�•"1 t` „L N ',�+1.`A"':t " C b tot , " T",�.r. •'�""'� r*wt. �r�..:+�0. �iRn,. ..� +�3�`� \M• �,►"`�F l�1 ���•�.�Y ~.. 1�e. w .• F ..'� - a. ''� ++i�lrw�? w �'g�, ,,� ���'9n`�l.ac s.Y.�� �`:.`::rSv� ` va r=. ♦ yr' ♦ ;, Y _ ♦ wM mow. •�� 'Ra !V':� - :, Jwi6-r:� >..: � � � �..e -- NAME OF OFFEN ER /fh Q s e A1,Q66316 6316 TOWN OF ADDRESS OF0 N E , Y BARNSTABLE CITY,STATE, P DE ! - 1 '� pf IME ' MV/MB REGISTRATION NUMBER OFFENSE PANSSTANIX. W MASS. p, I 1. Vf• CL �G39• �S .t O RFD IMy W TIME AND DAT 0 VIOLATION ��.0 TIO �0 VI LA 4 ^r c'� W NOTICE OF �A.N4 / P.Mp, ON 20M Y f Q VIOLATION SMATEOqF6fORCING PEpSONI y EAPO C DEPT. W I HEREBY ACKNO�EDGE RECEIPT OF CITATION X CL OF TOWN a ORDINANCE )(Unable to obtain i Ana urn of o nder. THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ J Date mailed ®� w OR YOU HAVE THE FOLLO IN ALTIRNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. W REGULATION (1)You may elect to pa the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, J before:The Barnstable Clerk,230 South Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, a Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. �N2 If yyou desire to contest this matter in a noncriminal proceeding,you mayy do so by making written request to DISTRICT COURT DEPARTMENT,FIRST STABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNS ABLE,MA 02630,Attn:210 Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fall to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due criminal complaint may be issued a ainst you. ❑ 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature r T NAME F � - �]C�/f1 '�/JiI 7/'/'1yf/t �T F/■�/ TOWN OF ADDR F FF N9ER W p 'CG/• I ril BARNSTABLE CITY.S ZIP /�t � oFIKE�Ok, / "' •i/•-{1 !f/1� MV/MB REGISTRATION NUMBER CL NAN�'�l'ANI.l;. ITyP !/iV/ w �ED.MP'� LL.I TIME AND DATE IOLATION r IQ IOLATAION �! \� r <� W NOTICE OF /� (A'w .•P.M. ONa 19 ,20V tA)A F 't. Q URA OF EN OR�ING P sb�r EN D Pdi r• f BADS E p10.(� C SIG VIOLATION " OF TOWN / Y H-REBY ACKNO6 • GE RECEIPT OF CITATION X Q ORDINANCE Unable to obtain s n e/JofftAO THE NONCRIMINAL FINE FOR THIS OFFENSE IS ls40,90rl ~ Date mailedLL, OR YOU HAVE THE FOLLOWI G L ERIIATIV WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. LU REGULATION LU (t)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,-Monday through Friday,legal holidays excepted, w before:The Barnstable Clerk;230 South Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. a (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this citation for a hearing. ' (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature NAME FEND jrjp .F*y-r �.,•11 7 f i � j/ J\ / ,.�?"^• _ YI71�. ., _ TOWN OF ADDR' E t `t)"7f�1) _\ll/ IF - r _ BARNSTABLE CITY,S A �P E �` Q, T �} r IIHE�pwh ` MV/MB REGISTRATION NUMBER G • OFFENSE ItAXVSI'AXIk:. ' w MASS A ISAa ,, CD l� CCL TFD MPy W TIME ANO DATE OF I CATION LOC�AT gN OE 10 ATION .y Z NOTICE OF cam. P.M.)oJ� ,, ,n,20 W w SI N TUR OF ENFORCING PERS' � �' E RCI DF'. ,f r eW BAO ��� ,�{^P N LU VIOLATION C/ U (y✓A/ (#J� 0 OF TOWN 1 EREBY ACKNOWL(I GE RECEIPT OF CITATION X LU Q ORDINANCE A Unable to obta' i to re f.offg�d r. THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ � Date mailed _ "' w OR YOU HAVE THE FOLLO IN AL ERN'ATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION^WITH NO RESULTING CRIMINAL RECORD. w Cn REGULATION w (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, before:The Barnstable Clerk,230 South Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, J Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. a (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST BARNSTABLE DIVISION,COURT COMPOUND, MAIN STREET, BARNSTABLE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ ,Signature NAME OF OF DE ��.. ✓ i .` JBAR 66317 TOWN OF ADDRESS F NDER If BARNSTABLE CITY,ST IP ODE �j ( �y 1ME ' `� MV/MB REGISTRATION NUMBER OFFENSEDa LLI V 6A Ce �1ASS. CL 167q. tf0 � W TIME AND DATE 0 V OLATION LOV OLATION r�W NOTICE OF ( I ,fu1 6N ,20 / >D Q SI ATU E F 6 NG ERS N _ EN 6 C :E r ADG 0 W VIOLATION /�r p �' Kt1 t�l o Uj OF TOWN I HEREBY ACKNOWI I E RECEIPT OF CITATION X CL ORDINANCE Unable to obtain ' 14 rdof of nder. a THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ aQJ ~J Date mailed w OR YOU HAVE THE FOLLOWING ALIT RNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w REGULATION rn (1)You may elect to pa the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, J Hyannis,lore e Barnstable rnst bWITHIN T 230 South WENTY-ONE(21)DAYSIOF THE DAT or E OF THISINOTICE.ck,money order or postal note to Barnstable Clerk,P.O.Box 2430, a �2)1 If you desire to contest this matter in a noncriminal proceeding,you may,do so by making written request to DISTRICT COURT DEPARTMENT,FIRST AR ySTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNS TABLE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due criminal complaint may be issued a ainst ou. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature ' NAME AND�KEI+.S le TIV,I.'\. 7 BAR 3 TOWN OF ADDR SS OF OFFEND { + /gyp WA M5 _ V O� : . �. � r BARNSTABLE CITY,STAT ZI CO _,rt� Z -f� /"� f P`Of THE)qk� MV/MB REGISTRATION NUMBER BAHNSIARLE. OFFENS!T P ff/) �lED MPS ®f it LU TI A T LATION - LOCATION OF VIOLATION ,/ W NOTICE•OF P.M. ON _ 20 �'/? �( V_ « r wi F J ,;SIGN 111F0 CI G PE3�ON / ENFO Cl G PT ` ° BADS fJ'0. w -V1OL-ATION �� t t� A T o LU 100TOWN I HEREBY ACKNOWLEDGE/RECEIPT OF CITATION X a Unable to obtain si atu e f ffe er. ORDINANCE 9 THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ Date mailedCL ! ,r D w OR YOU HAVE THE FOLLOWING AL ERN. IVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w REGULATION (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, w before:The Barnstable Clerk,230 South Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, J Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. a (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this citation for a hearing. 1 (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature NAME OF OFFENDER r__�' ,""'}aSSEPP ,yes BAR TOWN OF ADDRESS OE JE RdllrW �� � /•`il�C�l�� • F "/7�I/>1 V a BARNSTABLE /I;/� DIME 7aY 1lI It MV/MB REGISTRATION NUMBER ///�+► .�/"//�� IIAN\ATApI.E.$ OFFENSE yj / L MASS. t � F679. r — o O �rED INS W TIME ANOD nOFVIOLATION LOC �OIOLATOJJ 1 J+ ' W NOTICE OF (A.M./ P 20 1.M.)ON 11 /! /b{(TG Q SIG 'MU OF ENFORC NG PFRSO d Lx I&PTI � Cn� L VIOLATION O OF TOWN I�UrEREBY ACKNOWLEDGE RECEIPT OF CITATION X a ORDINANCE (�Unable to obtain si na,Zu jo�f ffend�r. F— ` n4j And ir, THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ � Date mailed LU uu OR YOU HAVE THE FOLLOWING ALT RNA VES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a. DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w REGULATION a (1)You may elect to pa the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, w CL before:The Barnstable Clerk,230 South Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, j Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. (2 Uyou desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST NSTABLE DIVISION,COURT COMPOUND,MAIN STREET,6ARNSTABLE,MA 02630,Attn:210 Noncriminal Hearings and enclose a copy of this citation for a hearing, (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due criminal complaint may be issued against You. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature - ..-. r -^^,. `-- -�: a---.....rvT.��rr.,,�>....s.^,.",'.-..fix t ��,�,inw.;r�€ss,mrcr �• -. pa-r+.n.^�"*P'�-�..^ ",`v,v n.:..r,r^"3��.`'t rT.,rx-. TOWN OF BARNSTABLE ' BAR-W Ordinance or Regulation WARNING NOTICE " Name of Offender/Manager p -s�e ,. �,P Address of Offender 16,q WA k19At'! ry MV/MB Reg.# Village/State/Zip m A 125� Business Name ,f'' eam/�m on 1/1 200 Business Address Signature of,"Ealoricing Office Village/State/Zip Location of Offense _ 111 K . �# ,( A�'.,l)ZAro, _ Enforcing Dept/Division Offense w ./ .i�#d n t � 1R,0- ;/V, (41,'��� � Facts f/lll/V l if r r 11� IVAC14d: •� Iroj�r- f&M I-37w*ATrf frrr., or 10&--M. 96 This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. DGS i ;a WHITE-OFFENDER CANARY-ORD.7REG.-PROG. PINK-.ENFORCING OFFICER GOLD-ENFORCING DEPT. i TOWN OF BARNSTABLE BAR-W ► Ordinance or Regulation WARNING NOTICE. Name of Offender/Manager Ar. Address of Offender M am W, 9M V ',' }+ MV/MB. Reg.#' Village/State/Zip f."^ r°�d, { Business Name apm on Business Address Signature of `Enforcing Officer " Village/State/Zip ` ,. Location of Offense , ! Enforcing �Dept/Division 41 Offense Factsjjtj�j , * � UNk � P d This will serve'only as a warning. At this time no legal action has been taken. It is the goal of Town agencies ' to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal ry action by 'the Town. '' ,� ' dF , ' < r, •. WHITE-OFFENDER CANARY ORD/REG-PROG "PINK-ENFORCING OFFICER GOLD ENFORCING DEPT. TOWN -,OF BARNSTABLE BAR-W © 3670 Ordinance -or Regulation WARNING NOTICE _- Name of Off ender/Manager -l� Pl.,,��Q�--"� ) y�jk- "Address-of Offender ,, �,9 /d MV/MB Reg.# w r. r � . Village/State/Zip '7 1/52 Business Name ,.�.,, amf/pm; one0 Business Address r+ j1 `�t a ' w Signature of' En Officer Village/State/Zip Location of Offense Vag f "`��y Enforcing Dept/`D`ivi"sion Offense j;60*flft �1 l�tlr� 1i l Facts f"Y-1A-#3 OL V440 C-4- X aI �O r Y PARn, (j1j jJ�(�jrf This will serve only as' a warning. At thils time"tio legal `action has been takerV. It is the goal of Town, agencies to achieve .voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subseqlient violations will result inO appropriate legal action by the Town. INK //r (�-y 'J KIK WHITE-OFFENDERCANARY-ORD./REG.-PROG. - FOR i OFFICER GOLD ._.s-. cz-..,`r`^'S`a .'e`+ nL.-..q..+�....y-<-,l—T- TOWN OFF BARNST4 ._LE BAR-W � Ordinance or' Regulation WARNIN , NOTICE r�. Name of Offender/Manager , ' Addtess-•of Offender � 1 ., , 1tY'.�� s fl ell_,,.,, MV/MB Reg.# " ^Village/State/Zips / �a Business Name t yam:/pm; ono 04— ,J Business., Address jr t Signature of-Enfozcing Officer Village/S'tate/Zip ` '�"� , Location of Offense /( ` � .~. �1 ` � f/ ''' Enforcing Dept/`Division Offense �'rsT .%'t3�t �!# 1 .f 'fiV Facts111111 3� i' lf 'iiY�-f r )1 � Icm This will serve only as a warning. At this time no legal `action has been taken'. It is the `goal .'of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and ,Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result ins appropriate legal ae�t_i�on by the;,Town WRIO WHITE-OFFENDER CANARY-'OAD./FiG=PROG. INK ) !Y OFFICERiGOLD-E FOR�10[ ^. P T ru mF.. FL `. N Diu Postage $ 6 v O 1Er Certified Fee p�/ Retum Receipt Fee jr� oHOM� 0 (Endorsement Required) f N a Restricted Delivery Fee -� C3 (Endorsement Requ % C3 Total Postage&Fees $ � J I- I Er Z, C3 Street,APL N 9 � or PO Box No.. M C/ty»...t»--- 0 Z C� Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece o A signature upon delivery n A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is, required. a For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Deliver)?% o If a postmark on the Certified Mail receipt is desired,please present the arti- cle,,at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,January 2001 (Reverse) 102595-M-011-2425 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVEPY ■ Complete items 1,2,and 3.Also complete A. Sign re item 4 if Restricted Delivery is desired. / ❑Agent ■ Print your name and address on the reverse / ❑Addressee so that we can return the card to you. B. Receiv y(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, ,�.� t . or on the front if space permits. ` l t b' D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No 3. Service Type❑Certified Mail ❑ Express Mail �( ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. �J 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number ! 7001. .1940 .0004 90.42 2362 I' (f'ransfer from service _ 1 PS Form 3811,August 2001 Domestic Return Receipt 102595.02-M-1540 UNITED STATES POSTAL SERVICE O First-Class Mail Postage&Fe!8.P aid_PermUSPs`No:G- 0 • Sender: Please print y urn-nagie ddress, and ZIP+4 in this box • Public Health Division Town Gf'R nstat le'" 200 Main Street Hyannis,Massachwsetts:02601.: THE COMMONWEALTH OF MASSACHUSETTS OFFICE OF THE ATTORNEY GENERAL ZOO PORTLAND STREET BOSTON, MA'SSACHUSETTS 02114 Y yV THOMAS F.REILLY ;;I ATTORNEY GENERAL t 6,17 727-2200 .www,ago.state.ma:us October 2, 2003 Ms. Donna Miorandi ; Regulatory Services Town of Barnstable 200 Main Street Hyannis, MA 02601 Re: Commonwealth of Massachusetts, Department of Public Health v. Peter Klusky Dear Ms. Miorandi: Thank you for faxing back the copy of the Affidavit I sent to you. Enclosed you will find another copy of the same Affidavit—unsigned. Please sign this copy too, and then mail it back to me. This will be used for the Court papers. Thanks also for letting me know that Full Service Vending has more machines operating in your Town. Sincerely, nco J. urne, Assistant Attorney General t~.1 T -1.,..1.. ._ Office of Attorney General r comas F. Reilly , [AA 200 Portland Street ` �o 4 Boston, MA 02114 �, I'M O^T� http://www.ago.state.ma.us 2 agCn O !/I f 5790o' 5,,, Ms. Donna Miorandi Regulatory Services Town of Barnstable 200 Main Street Hyannis, MA 02601 50%RECV®PAPER ...i..w'.:.,3_f J. 30%POST-CONSUMER i I COMMONWEALTH OF MASSACHUSETTS SUFFOLK, ss. SUPERIOR COURT C.A.No. 00- COMMONWEALTH OF MASSACHUSETTS, ) DEPARTMENT OF PUBLIC HEALTH ) Plaintiff ) V. ) PETER KLUSKY, ) Defendant ) AFFIDAVIT OF DONNA Z. MIORANDI I, Donna Z. Miorandi, hereby depose and state that I have personal knowledge of the following facts: 1. I am employed as a health inspector in the Public Health Division of the Regulatory Services for the Town of Barnstable. 2. I have been employed as a health inspector in the Town of Barnstable since September 1987. 3. On June 30, 2003 I acted upon reports of a vending machine dispensing food that was giving off a strong odor of gasoline. 4. I went to a location where a vending machine labeled as belonging to Full Service Vending, 709 Wakeby Road, MA, was in operation for the public. 5. I examined the packages of food I found in that machine, and they smelled heavily of gasoline. 6. I then confiscated all the tainted food. f 7. Upon further investigation, I determined that the owner of the vending machine was Peter Klusky, and that he was unlicensed to operate a food vending machine business in Massachusetts, and that he had machines in a least one more location in the Town of Barnstable. 8. I then alerted the Massachusetts Department of Public Health, the Division of Food and Drugs (hereinafter, DPH) to the situation. 9. The DPH also determined that Peter Klusky owned the vending machines, and that he was not licensed to operate a food vending machine business in Massachusetts. 10.On July 11, 2003, DPH notified me that they served Peter Klusky with a Notice To Cease And Desist: the operation of his unlicensed, and unsanitary food vending machine business. 11.Since that date, Peter Klusky has continued to operate his unlicensed business. 12.On September 17, 2003, I revisited the two locations that had been in possession of Peter Klusky's food vending machines, and the machines were still in operation. Sworn to under the pains and penalties of perjury on this day of October 1, 2003. 0 0 DONNA Z. MIORANDI Ft rati Town of Barnstable Regulatory Services * BARNSTABLE, y MASS. g Thomas F.Geiler,Director �ArE0 39.� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 October 2,2003 Paul J. Tierney,Director Division of Food and Drugs 305 South Street Jamaica Plain,MA 02130 RE: Full-Service Vending,Peter Kluskey,709 Wakeby Road,Marstons Mills Dear Mr. Tierney: This morning the Town of Barnstable Health Department became aware of more vending machines in the town that are serviced and in full operation by Peter Kluskey doing business as Full Service Vending. A soda and snack machine is in operation at the Town of Barnstable landfill located at Flint Street,Marstons Mills. The second site is also a soda and snack machine at the Town of Barnstable Highway Department located at 382 Falmouth Road,Hyannis. Thank you for your attention in this matter. Sin Donna Z.Miorandi,R Health Inspector P. 1 * * COMMUNICATION RESULT REPORT ( OCT. 2.2003 1:44PM ) TTI BARNSTABLE BOARD OF HEALTH FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE ---------------------------------------------------------------------------------------------------- 091 MEMORY TX 916177273076 OK P. 4/4 ---------------------------------------------------------------------------------------------------- REASON FOR ERROR E-1) HANG UP OR LINE FAIL E-2) BUSY E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION Town of Barnstable LE. : Rep-1 ry Services . Mum 1k Thou F. "er,Director Public Health Division Thomm McKean,Director 200 Main Street, Hyannis,MA 02601 DATE: NUMMER OF PAGES TO FOLLOW: TO: FROM: -6 I Lam 9 PHONE: PRONE: (S08)$67,46" FAX PHONE: =PRONE; (508)790.6304 Town of Barnstable Regulatory Services KAM 9�a %639. �0 Thomas F. Geiler, Director A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 - 9 DATE: 070� 67) NUMBER OF PAGES TO FOLLOW: TO: ) �f� � FROM: V j J PHONE: PHONE: (508)8624644 FAX PHONE: J �f FAX PHONE: (508)790-6304 cc: NOTES/COMMENTS: Q:UMALTH\Fax Forms doc FZHE r�y� Town of Barnstable Regulatory Services * BMWSTABLE. y MASS. g Thomas F.Geiler,Director s6g9. �0 ATEo►��A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 October 2 2003 Paul J.Tierney,Director Division of Food and Drugs 305 South Street Jamaica Plain,MA 02130 RE: Full-Service Vending,Peter Kluskey,709 Wakeby Road,Marston Mills Dear Mr. Tierney: This morning the Town of Bamstable Health Department became aware of more vending machines in the town that are serviced and in full operation by Peter Kluskey doing business as Full Service Vending. A soda and snack machine is in operation at the Town of Barnstable landfill located at Flint Street,Marstons Mills. The second site is also a soda and snack machine at the Town of Barnstable Highway Department located at 382 Falmouth Road,Hyannis. Thank you for your attention in this matter. Smc rely, _ O Donna Z.Miorandi,R Health Inspector Cc: Franco Goboume,Assistant Attorney General 5 P. 1 COMMUNICATION RESULT REPORT ( OCT. 2.2003 1:41PM ) TTI BARNSTABLE BOARD OF HEALTH FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE ---------------------------------------------------------------------------------------------------- 090 MEMORY TX 916175248062 OK P. 2/2 ---------------------------------------------------------------------------------------------------- REASON FOR ERROR E-1) HANG UP OR LINE FAIL E-2) BUSY E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION Town of Barnstable � Re ato Services� rY Thomas F.QUer,Director Public Health Division Them=Mean,Director 200 Main Street, Hyannis,MA 02601 DATE: ?01A 103 NER OF PAGES TO FOLLOW: T0: PAFROM: � 121� PHONE: PHONE: (508)86246" r FAX PHONE: ) r0 FAX PONE- (508)790.6304 CC: / OCT. 1. 2003 9: 35AM ATTORNEY GENERAL 617 7273076 NO. 178 P. 1 Ti-iE COMivIONWEALTH OF MASSACHUSETTS OFFICE OF TIdE ATTORNEY GENERAL 200 PORTLAND STREET BOSTON, MASSAC14USEM 02114 TOM REILLY ArroRHc,cGe;ew. (617) 727.2200 FAX OVER SHEET x�-«ago sxacc,ma us TO: �(O�d; FAX NO(S): FROM. Assistant Aaorney General Trial Division, 3rd Floor TELEPHONE (617) 727-22OO Ext. NO.OF PAGES: (Includes Cover Sheet) DATE- D4�0 0 ('lease tali upon receipt O ['Lease hand del«er co addressee immediatcly O Original Will Follow via O Origiaal Will Not FoRow NOTES: is is /77y57>vA C ' CONFIDENTIALITY NOTICE The documents accompanying this transmission contain information which may be confidential and/or privileged_ The information intended solely for the use of the addressee(s)named above. If you are not the intended recipient,you are advised that any disclosure,copying,distribution or use of the information transmitted is prohibited• If you have received this transmission in error, please notify the sender immediately by telephone and return the original transmission by first class mail. Thank you for your compliance. IF THERE ARE PROBLEMS RECEIVING THIS TRANSMISSION, PLEASE CONTACT THE SENDER AS SOON AS POSSIBLE t Town of Barnstable s IIJAMST ABM Regulatory Services ' � Thomas F. Geiler,Director A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 7DAT'E:70 NUMBER OF PAGES TO FOLLOW: TO: 8 , ) FROM: tl3 PHONE: PHONE: (508)862-4644 FAX PHONE: FAX PHONE: (508)790-6304 �� cc: NOTES/COMMENTS: Q:WEALIW%Fax Form.doc OCT. 1. 2003 9: 35AM ATTORNEY GENERAL 617 7273076 NO. 178 P. 2 COMMONWEALTH OF MASSACHUSETTS SUFFOLK ss. SUPERIOR COURT C.A.No.00- COMMONWEALTH OF MASSACHUSETTS, ) DEPARTMENT OF PUBLIC HEALTH ) Plaintiff ) V. ) PETER KLUSKX, ) Defendant ) AFFIDAVIT OF DONNA Z. MIORANDI I, Donna Z. Miorandi, hereby depose and state that I have personal knowledge of the following facts: 1. I am employed as a health inspector in the Public Health Division of the Regulatory Services for the Town of Barnstable. 2. I have been employed as a health inspector in the Town of Barnstable since September 1987. 3. On June 30,2003 I acted upon reports of a vending machine dispensing food that was giving off a strong odor of gasoline. 4. I went to a location where a vending machine labeled as belonging to Full Service Vending, 709 Wakeby Road, MA, was in operation for the public. 5. I examined the packages of food I found in that machine, and they smelled heavily of gasoline. 6. I then confiscated all the tainted food. OCT. 1, 2003 9: 35AM ATTORNEY GENERAL 617 7273076 N0, 178 P. 3 7. Upon further investigation, I determined that the owner of the vending machine was Peter Klusky, and that he was unlicensed to operate a food vending machine business in Massachusetts, and that he had machines in a least one more location in the Town of Barnstable. 8. 1 then alerted the Massachusetts Department of Public Health, the Division of Food and Drugs (hereinafter,DPH) to the situation. 9. The DPH also determined that Peter Klusky owned the vending machines, and that he,was not licensed to operate a food vending machine business in Massachusetts. 10.On July 11, 2003, DPH notified me that they served Peter Klusky with a Notice To Cease And Desist: the operation of his unlicensed, and unsanitary food vending machine business. 11.Since that date, Peter Klusky has continued to operate his unlicensed business. 12.On September 17, 2003, I revisited the two locations that had been in possession of Peter Klusky's food vending machines, and the machines were still in operation. Sworn to under the pains and penalties of perjury on this day of October 1, 2003. m DONNA Z. MIORANDI C oFt tati Town of Barnstable Regulatory Services anFwsrABM y� 1Mnss. 10g Thomas F.Geiler,Director pTFo3�A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 October 2,2003 Paul J.Tierney,Director Division of Food and Drugs 305 South Street Jamaica Plain,MA 02130 RE: Full-Service Vending,Peter Kluskey,709 Wakeby Road,Marstons Mills Dear Mr.Tierney: This morning the Town of Barnstable Health Department became aware of more vending machines in the town that are serviced and in full operation by Peter Kluskey doing business as Full Service Vending. A soda and snack machine is in operation at the Town of Barnstable landfill located at Flint Street,Marstons Mills. The second site is also a soda and snack machine at the Town of Barnstable Highway Department located at 382 Falmouth Road,Hyannis. Thank you for your attention in this matter. Sinc rely, O yes Donna Z.Miorandi, Health Inspector Cc: Franco Goboume,Assistant Attorney General r P. 1 COMMUNICATION RESULT REPORT ( OCT. 1.2003 8:01AM ) TTI BARNSTABLE BOARD OF HEALTH FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE ---------------------------------------------------------------------------------------------------- 076 MEMORY TX 916177273076 OK P. 3/3 i - - ----------------------------------------------------------------------------------------------- REASON FOR ERROR E-1) HANG UP OR LINE FAIL E-2) BUSY E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION Town of Barnstable Regulatory Services 3 . Thomas F. GeHer,Director Public Health Division Thomas McKean,Director 200 Maur Street, Hyannis,MA 02601 DATE: 0-3 NUMBER OF PAGES TO FOLLOW: TO: FROM. ) PHONE: PHONE: (508)862.4644 FAX PHONE: r r FAX PHONE; (508)790.6304 ti Town of Barnstable Regulatory Services bUft 9� 16 9. `0$ Thomas F. Geiler,Director prEo" a Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 DATE: 0-3 NUMBER OF PAGES TO FOLLOW: TO: FROM. ) DOM d PHONE: PHONE: (508)8624644 FAX PHONE: FAX PHONE: (508)790-6304 cc: NOTES/COMMENTS: QAHEALnWax Form.doc SEP- 29. 2003 2: 59PM ATTORNEY GENERAL 617 7273076 NO. 148 P. 1 _ TEiE COMMONWEALTH OF MASSACHL3SETTS OFFICE OF THE ATTORNEY ClrENERA[. 200 PORTLAND SMUT Bosrw MASSAC14USEM 021 14 rom REMLY r ArroRNcYGEN:EPAj. t`AA�r CO yerG� SHLG lcr�r (617) 717 ZZQO Aw%,W ago state Maus TO: FAX NO(S): o �3 o r-FROM: �p Assistant Acrorney General Trial Division, 3rd Floor TELL-P 0Kr,#. (617) 727-2200 Ex-c. luz NO,OF PAGES. (Includes Cover Sheet) DATE k2 ['lease call upon receipt Please hand deli�-er to addressee iauned<atcly 0 Original Will Follow via- ❑Original Will Not Fol(ow NOTES: X.�dd.� v� V►"4' e Cc�R� O� 5 OrL 40/ CONFIDENT(ALRY NOTICE The documents accompanying this transmission contain information which may be confidential and/or privileged. The information intended solely for the use of the addressees)named above. If you are not the intended recipient,you are advised that any disclosure,copying,distribution or use of the information transmitted is prohibited. (f you have received this transmission in error, please notify the sender immediately by telephone and return the original transmission by first class mail. Thank;you for your compliance. iF THERE ARE PROBLEMS RECEIVING THIS TRANSMISSION, PLEASE CONTACT THE SENDER AS SOON AS POSSIBLE _ - SEP. 29. 2003 2: 59PM ATTORNEY GENERAL 617 7273076 N0. 148 P. 2 COMMONWEALTH OF MASSACHUSETTS SUFFOLK, ss. SUPERIOR COURT C.A.No. 00- COMMONWEALTH OF MASSACHUSETTS, ) DEPARTMENT OF PUBLIC HEALTH ) Plaintiff ) V. ) PETER KLUSKY, ) Defendant ) ----------------------- ----- AFFIDAVIT OF DONNA Z. MIORANDI I, Donna Z. Miorandi, hereby depose and state that I have personal knowledge of the following facts: 1. I am employed as a health inspector in the Public Health Division of the Regulatory Services for the Town of Barnstable. 2. I have been employed as a health inspector in the Town of Barnstable since September 1987. 3. On June 30, 2003 I acted upon reports of 2 vending machine dispensing food that was giving off a strong odor of gasoline. 4. I went to a location where a vending machine labeled as belonging to Full Service Vending, 709 Walceby Road, MA, was in operation for the public. 5. I examined the packages of food I found in that machine, and they smelled heavily of gasoline. SEK 29. 2003 2; 59PM ATTORNEY GENERAL 617 7273076 NO. 148 P. 3 6. I then had the machines shut off pen�p'ng further inve gation, n d confiscated the food. 7. Upon further investigation, I determined that the owner of the vending machine was Peter Klusky, and that he was unlicensed to operate a food vending machine business in Massachusetts, and that he had machines in a least one more location in the Town of Barnstable. S. I then alerted the Massachusetts Department of Public Health, the Division ------------ of Food and Drugs (hereinafter, DPH)to the situation. 9. The DPH also determined that Peter Klusky owned the vending machines, and that he was not licensed to operate a food vending machine business in Massachusetts. 10.On July 11, 2003, DPH notified me that they served Peter Klusky with a Notice To Cease And Desist: the operation of his unlicensed, and unsanitary food vending machine business. 11.Since that date, Peter Klusky has continued to operate his unlicensed business. 12.On September 17, 2003, 1 revisited the two locations that had been in possession of Peter Klusky's food vending machines, and the machines were still in operation. Sworn to under the pains and enalties of per ry . 29`h day of September, 2003. DONNA Z. MIORANDI �oFt ra,� Town of Barnstable Regulatory Services * BMMSTABLE, s y MASS. g Thomas F.Geiler,Director � s639. �0 039. a Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 19,2003 Paul J. Tierney,Director Division of Food and Drugs 305 South Street Jamaica Plain,MA 02130 RE: Full-Service Vending,Peter Kluskey,709 Wakeby Road,Marstons Mills Dear Mr.Tierney: Enclosed are some pictures taken recently of the vending machines located at businesses in Hyannis that we know are in operation. Additionally,I have sent along some pictures of his property where the vending machines and food are located. Thank you for your attention in this matter. Sincerely, Donna Z.Miora RS Health Inspector oFt�E ra,. Town of Barnstable Regulatory Services + BARNSTABLE, y MASS. $ Thomas F.Geiler,Director 1639. ♦� A'Fp,9�a Public Health Division Thomas McKean,Director 367 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 17,2003 Paul J. Tierney,Director Division of Food and Drugs 305 South Street Jamaica Plain,MA 02130 RE: Full-Service Vending,Peter Kluskey Dear Mr.Tierney: As requested,I revisited the sites of Cape Tire,95 Falmouth Road,Hyannis and Country Garden,West Main Street,Hyannis. Both sites still have vending machines that are fully operational. The owner of Cape Tire stated that Mr.Musky has recently filled it up and also mentioned that they have not received any commission from Mr.Kluskey for these machines in the past year. Users of the machine have also stated that the candy seems old at times and the sodas are out of date. Thank you for your attention in this matter. Sincerely, Donna Z.Miorandi,R Health Inspector Health Complaints 17-Sep-03 Time: Date: Complaint Number: Referred To: Taken By: Complaint Type: Article X Detail: J Business Name: Number: Street: Village: Assessors Map_Parcel: Complainant's Name: Address: Telephone Number: Complaint Description: 1 'I P. 1 COMMUNICATION RESULT REPORT ( SEP.17.2003 1:28PM ) TTI BARNSTABLE BOARD OF HEALTH FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE ---------------------------------------------------------------------------------------------------- 021 MEMORY TX 916179836770 OK P. 2/2 ----------------------------- --- REASON FOR ERROR E-1) HANG UP OR LINE FAIL E-2) BUSY E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION Town of Barnstable : Regulatory Services w p�Rty"esm - � Thomas F. Geiler,Director S Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,Mtn 02601 DATE: NUMBER PAGES TO FOLLOW: TO: FROM- a s PHONE: PHONE: (548)8624644 FAR PHONE: jg& FAX PROINE: (SOS)79p•6304 ce: Town of Barnstable ,�i1S1Ae Regulatory Services 9� ° Thomas F. Geiler,Director a,Eo" a Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 DATE: NUMBER PAGES TO FOLLOW: TO: � FROM; e / l PHONE: PHONE: (508)862-4644 FAX PHONE: g JJ� FAX PHONE: (508)790-6304 cc: NOTES/COMMENTS: Q:UEALTH\Fax Form.doc �I Jul-11-03 09:39am From-D P H FOOD AND DRUG $17-983-6770 T-633 P-01/03 F-595 305 South Street, Jamaica Plain , MA 02130 MA Departivient of Public Health Phone-(617)983-6773 Fax: (617)983-6770 Priscdia.neves@state ma.us ' • • • • Drugs ftx To: Donna Moirandi From: PRISCILLA NEVES, MEd, IRS Food Safety Specialist Fax: 508-790-6304 Pages: 1 (Including Cov®r sheet) Phone: Date: 7 — e/—p Re: ;;Z:�'/'4""e c �. _ i cc: ❑ Urgent ❑_For Review ❑ Please Comment M Please Reply 0 Per Request L Ju1-11-03 09:40am From-D P H FOOD AND DRUG 61T-983-6770 T-633 P.03/03 F-595 If you have questions regarding this Notice,please contact me at(617)983-6712. Sincerely, Paul J Tierney,Director Food Protcction Program cc: Howard Saxner,Deputy General Counsel, MDPH Donna Miorandi,Barnstable Board of Health LN/cnf0rmcemcnv1K1W, Y1-11-03 Jul-11-03 09:40am From-D P H FOOD AND DRUG 617-983-6770 T-633 P.02/03 F-595 ��- The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health Division of Food and Drugs 305 South Street, Jamaica Plain, MA 02130-3597 MITT ROMNEY (617)983-6700 (617) 524-8062- Fax GOVERNOR KERRY HEALEY LIEUTENANT GOVERNOR RONALD PRESTON SECRETARY CHRISTINE C.FERGUSON COMMISSIONER Mr. Peter Klusky July 11,2003 Full Service Vending First CIass and Certified Mail 709 Wakeby Rd Certified No: 7001 1940 0005 9855 6891 Marston Mills,MA, 02648 Re: NOTICE TO CEASE AND DESIST THE OPERATION OF A FOOD VENDING MACHINE BUSINESS. Dear Mr.Klusky: On June 30,2003,the Barnstable Board of Health informed our office that you are operating a food vending machine business under unsanitary conditions and without a license to operate a food vending machine operation issued by the Department. Pursuant to 105 CMR 590.000-Minimum Sanitation Standards for Food Establishments -Chapter X,no person shall conduct a food vending machine operation without a license from the state depanment of public health. Any person who violates any provision of 105 CMR 590.000 shall,upon conviction,be punished for a first offence by a fine of not more than one hundred dollars and for a subsequent offence by a fine of not more than five hundred dollars. Therefore,Full Service Vending may not operate a food vending operation,until and unless the Department of Public Health("Department")issues a license to Full Service Vending to operate a food vending machine.Anyone continuing to operate a food vending machine operation in the absence of a valid license from the Department is in violation of 105 CMR 590.018: Vending Machines. Full Service Vending is hereby directed to immediately cease the operation of all food vending machines. If Full Service Vending fails to cease the operation of all food vending machines,the Department will have no option but to refer this matter for further enforcement action. °FtHE r Regulatory Services ti Thomas F. Geiler, Director * snxtvsrnB�e, - 9� Public Health Division ArEo �A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 zz SIB IIETRAN F MIAL , DATE: NUMBER OF PAGES TO FOLLOW: TO: k i/� / FRO w R& PHONE: Og �� D�O PHONE: (508)862-4644 FAX PHONE: FAX PHONE: (508)790-6304 &a3 cc: r dPleaf� Coe NOTES/COMMENTS: © i V � v 4 e Q:\HEALTI-ITax Form.doc t Health Complaints 13-Jun-05 Time: 9:00:00 AM Date: 6/13/2005 Complaint Number: 18181 Referred To: DAVID STANTON Taken By: DAVID STANTON Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH Article X Detail: UNSANITARY CONDITIONS Business Name: Number: 709 Street: Wakeby Road Vi age: MARSTONS MILLS Assessors Map_Parcel: 028-025-001 Complainant's Name: Address: Telephone Number: Complaint Description: The house is still bad here. Some of it was cleaned up, but there is still a pile there. Actions Taken/Results: DS WENT TO SAID LOCATION. SEVERAL PHOTOS ON FILE. DS WILL TRY TO GET A HOLD OF THE NEW OWNER TO SEE WHAT HIS PLANS ARE. 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M �.! - � `t,�o 3 ! /` �<'r�"� • ."5'l.0 _ to r r .� -,�A•, y�'' v +�ka' +,� �'t � t 94`�'' +I N � t t • , Health Complaints 16-Jul-03 Time: 2:00:00 PM Date: 11/7/2002 Complaint Number: 3865 Referred To: DONNA MIORANDI Taken By: DONNA MIORANDI Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH Article X Detail: Business Name: Full Service Vending Number: 709 Street: Wakeby Road Village: MARSTONS MILLS Assessors Map_Parcel: Complainant's Name: anonymous Address: Telephone Number: Complaint Description: Anonymous male official reporting a home with much debris of cars and old soda machines operating out of his home without a home occupation permit or a vending permit from the state. Actions Taken/Results: DZM investigated-sent warning and shall send subsequent tickets if no compliance. DZM has notified the State Division of Food and Drug about operating without a permit. Investigation Date: 11/15/2002 Investigation Time: 5:15:00 PM 1 Health Complaints 16-Jul-03 Time: 3:00:00 PM Date: 6/30/2003 Complaint Number: 4136 Referred To: DONNA MIORANDI Taken By: RITA Complaint Type: ARTICLE X- FOOD Article X Detail: PRODUCT INTEGRITY Business Name: Cape Tire Service Number: 45 Street: Falmouth Road Village: HYANNIS Assessors Map_Parcel: Complaint Description: from Cape Tire Service called to state that animal crackers bought in a vending machine at their workplace tasted/smelled like gasoline. Actions Taken/Results: DZM investigated and three packages were open and when sniffed inside they smelled LIKE gasoline. DZM opened one on site and it also smelled like gasoline. David Stanton opened one on 7/1/03 and it didn't smell at all. 8 packages remain in the office unopened. DZM called She seems to think it is from the truck filling up with gasoline. DZM spoke to Linda again on 7/1/03 and e- mailed Priscilla Neves as well regarding this matter. Linda is going to talk with Priscilla and with the FDA in North Carolina. Product is Austin Zoo animal crackers, Austin Quality Foods, Inc., One Quality Lane, Cary, NC 27519- 2004. An unlicensed vendor, Full Service Vending, 709 Wakeby Road, Marstons Mills, MA is the distributor to these vending machines. Owner of vending company is Peter Klusky, 508-420-1815. DZM sent a brief letter and copv of photos of property to Linda 1 Health Complaints 16-Jul-03 Sperandio at Division of Food & Drug. Investigation Date: 6/30/2003 Investigation Time: 3:30:00 PM 2 Health Complaints 16-Jul-03 Time: 3:00:00 PM Date: 6/30/2003 Complaint Number: 4136 Referred To: DONNA MIORANDI Taken By: RITA Complaint Type: ARTICLE X- FOOD Article X Detail: PRODUCT INTEGRITY Business Name: Cape Tire Service Number: 45 Street: Falmouth Road Village: HYANNIS Assessors Map_Parcel: Complaint Description: Charlie from Cape Tire Service called to state that animal crackers bought in a vending machine at their workplace tasted/smelled like gasoline. Actions Taken/Results: DZM investigated and three packages were open and when sniffed inside they smelled LIKE gasoline. DZM opened one on site and it also smelled like gasoline. David Stanton opened one on 7/1/03 and it didn't smell at all. 8 packages remain in the office unopened. DZM called She seems to think it is from the truck filling up with gasoline. DZM spoke to Linda again on 7/1/03 and e- mailed Priscilla Neves as well regarding this matter. Linda is going to talk with Priscilla and with the FDA in North Carolina. Product is Austin Zoo animal crackers, Austin Quality Foods, Inc., One Quality Lane, Cary, NC 27519- 2004. An unlicensed vendor, Full Service Vending, 709 Wakeby Road, Marstons Mills, MA is the distributor to these vending machines. Owner of vending company is Peter Klusky, 508-420-1815. DZM sent a brief letter and copv of photos of propertv to Linda 1 Health Complaints 16-Jul-03 Sperandio at Division of Food & Drug. Investigation Date: 6/30/2003 Investigation Time: 3:30:00 PM t 2 Miorandi, Donna From: Lomba, Lois Sent: Monday, July 07, 2003 4:03 PM To: Lavoie, Debbie; Karle, Darcy; Mattos, David; Miorandi, Donna Subject: Request for Written Incident Reports At your earliest convenience I will a need a written incident report for upcoming Barnstable First District Court arraignments for the following: Michael Renzi/BAR 66930/Conservation/Karle Peter Kluskey/BAR 66316: 66319 & BAR 49856: 49856/Health/Mattos and Miorandi Samantha DeDoming/BAR 65364 : 65365/Dog/Lewis Betty Curtis/BAR 52762/Dog/Lewis Thank you, Lois 4672 1 °FTM�rw,ti Regulatory Services °s Thomas F. Geiler,Director V•i • ! BAMSTABM 9� . ,�� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 NUMBER OF PAGES TO FOLLOW: FROM: D o -; C/A vd PHONE: PHONE: (508)862-4644 FAX PHONE: a FAX PHONE: (508)790-6304 cc: NOTES/CO NTS: � 9 C a 1 Q:\HEALTH\Fax Form.doc Austin Quality Foods, Inc. One Quality Lane Cary,NC 27513-2004 Austin Zoo Animal Crackers (net wt=2.125 oz. ) or 60g 12 packages total: Lot#P10113A9—3 unopened, 1 opened and no smell Lot#P06153C9—3 opened and strong smell Lot#P01193B5- 1 unopened Lot# P01193134— 1 unopened Lot# P0406387— 1 opened and strong smell, 2 unopened All of the above product was obtained from a vending machine located at Cape Tire Service, 45 Falmouth Road, Hyannis, MA 02601, phone# 508-771-1111 Vending Machine Operator is FULL SERVICE VENDING . Owners of vending machines are Peter&Maria Klusky, 709 Wakeby Road, Marstons Mills, MA 02648. Phone# is (508) 420-1815 TRANSMISSION VERIFICATION REPORT TIME: 06/30/2003 22: 20 NAME: FAX 915087906230 TEL 195087906230 DATE,TIME 06/30 22:19 FAX N0./NAME 916179836770 DURATION 00:00: 55 PAGE(S) 02 RESULT OK MODE STANDARD ECM Barnstable Assessing Search Results Page 1 of 2 t e yr y Home: Departments:Assessors Division: Property Assessment Search Results 70WAKEBYROAD Owner: KLUSKEY, PETER JOSEPH JR Property Sketch Legend Map/Parcel/Parcel Extension RPM 028 /025/001 ' 33333F %� N3"'3' f Mailing Address / a KLUSKEY, PETER JOSEPH JR '3' 5 q 1 My 709 WAKEBY RD MARSTONS MILLS, MA. 02648 Assessed Values: Appraised Value Assessed Value Building Value: $ 113,300 $ 113,300 Extra Features: $0 $0 Outbuildings: $0 $0 Land Value: $47,000 $47,000 Interactive Property Map: Ma requires Plug in: Totals:$ 160,300 $ 160,300 1 have visited the maps before Show Me The Mau April 2001 photos available Sales History: Owner: Sale Date Book/Page: Sale Price: KLUSKEY, PETER JOSEPH JR 2/15/1987 5577/226 $ 119,000 GREENBRIER CORP 9/15/1986 4950/282 $200,000 BARNSTABLE HOLDING CO ING 2/15/1986 4928/093 $0 Tax Information: Tax Rates: (per$1,000 of valuation) Town Tax $ 1,506.82 Town Fire District Rates Other Rates 9.40 Barnstable 2.88 Land Bank 3%of Town Tax C.O.M.M. FD Tax $246.86 C.O.M.M. 1.54 Cotuit 1.88 Land Bank Tax $45.20 Hyannis 2.89 West Barnstable 1.96 http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeSeivices/Finance/Assessing/As: 7/1/2003 Barnstable Assessing Search Results Page 2 of 2 Total: $ 1,798.88 Due to rounding differences these values may vary Land and Building Information Land Building Lot Size(Acres) 1 Year Built 1986 Appraised Value $47..000 Living Area 1306 Assessed Value $47.1000 Replacement Cost$ 121,867 Depreciation 7 Building Value 113,300 Construction Details Style Cape Cod Interior Floors Carpet Model Residential Interior Walls Drywall Grade Average Grade Heat Fuel Gas Stories 1 1/2 Stories Heat Type Hot Air Exterior Walls Wood ShingleClapboard AC Type None Roof Structure Gable/Hip Bedrooms 3 Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms 2 Bathrooms Total Rooms 6 Rooms Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value Property Sketch Legend BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area (Finished) UST Utility Area (Unfinished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http:Hwww.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/A... 7/1/2003 t : SODA FULL SERVICE VENDING Specializing in Pepsi Cola Vending Machines t � r 00 00 00 r Peter & Maria Musky 709 Wakeby Rd. \_ Marstons Mills,MA 02648 a - (508)420-1815 J� 11 _4-be_C ( �s� - a vv v V V v V T �, x � ,. �� l II r � _- � t � r -rl�� J � � Cr 07 r Ln M Postage .r44 Certified Fees �° :.D �•" ° Postmark y'.'s'... Return ReceiptlFe Here M (Endorsement Require S C3 C3 Restricted Dlivery Fe e c3 (Endorsement Require b Total Postage&Feegru M Sent To - v(.i r/ C3 _ Mr. Peke'— o p'h HIuskey, Jr.Street,Apt Nc C3 or PO Box No., 709 Wakeby Road C7 City,State,ZIF Marstons--Mills,MA 02648 i Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece o A signature upon delivery n A record"of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail or Priority Mail o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. e For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is required. 1 o For.-an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If,a postmark on the Certified Mail receipt is not needed,detach and affix iabel with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry._. PS Form 3800,January 2001(Reverse) 102595-01-M-1049 t SENDER: COMPLETE THIS SECTION • • ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Date of Delivery item 4 if Restricted Delivery is desired. .■ Print your name and address on the reverse so that we can return the card to you. C. Signa ■ Attach this card to the back of the mailpiece, X El Agent or on the front if space permits. ❑Addressee 1. Article Addressed to: D. Is delive address different from item 1? El Yes If YES,enter delivery address below: ❑ No Mr. Peter Joseph Kluskey, Jr. ('709,Vakeby Road - Mar-st ns.Mills.MA_0264,8 _ Ti 3. Service Type ❑Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. A` 7O--- 03_2O O 3. 66S ,5939 t. i < < PS Form 3811;July 1999, i Domestic Return Receipt 102595-99-M-1789 UNITED STATES POSTAL SERVICE' First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 • Sender: Please print yooi,ihame, address, and ZIP+4 in this box • I I Public Heft OWN M Town of Bamstabie P.O.Box 534 i HyannL%Massachusetts 02601 i i II ii yy ii ##ii !j ii ({ t 9 i j i �i>'t!allltitll!!��!!!!ll�aEi�ili!i!i!tit�ltt!tiita!'�!!�lt�tt�l�� F lad, Town of Barnstable Regulatory Services * sax►vsznaLE. Thomas F.Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 6, 2003 Mr. Peter Joseph Kluskey, Jr. 709 Wakeby Road Marstons Mills, MA 02648 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00 STATE SANITARY CODE II,MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION The property owned by you located at 709 Wakeby,Marstons Mills was initially inspected on November 15, 2002 and also on November 22, 2002 by Donna Miorandi,R.S.,Health Inspector for the Town of Barnstable,because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code II, Minimum Standards of Fitness for Human Habitation were observed: 410.602(B): Maintenance of Areas Free from Garbage and Rubbish Debris all over the entire property including but not limited to unregistered cars,many old vending machines, condensers,bags of empty soda cans, dollies,car parts, etc. Section 410.602 (B): Maintenance of Areas Free from Garbage and Rubbish of the State Sanitary Code clearly reads: `The occupant of any dwelling unit shall be responsible for maintaining in a clean and sanitary condition and free of garbage,rubbish, other filth or causes of sickness that part of the dwelling which he exclusively occupies or controls.' You are directed to abate this violation within seven(7)days of receipt of this notice In addition to the above listed violation you are also in violation of the following regulations: Town of Barnstable Regulation Article XXXIX,Control of Toxic and Hazardous Materials Storage of cans of Toluol outside on ground. You are directed to abate this violation within 24 hours of receipt of this notice Minimum Sanitation Standards for_Food Establishments State Sanitary Code,Article X 105 CMR 590.000 105 CMR 590.018: Running a vending machine business without a license from the State Department of Public Health. You are directed to contact this department and the STATE DEPARTMENT OF PUBLIC HEALTH and express your intention to comply. You are directed to apply for permits to come into compliance. Q:/health/wpfi les/kluskey.doc l You may request a hearing if written petition is received by the Board of Health within seven(7)days after the date order is received. However,these violations must be corrected regardless of any request for a hearing. Additionally,the Barnstable Police Department will be notified by this office of the unregistered cars located on the property. Please be advised that failure to comply with an order could result in a fine of not more than$500. Each separate days failure to comply with an order shall constitute a separate violation. PER ORDER OF T BOARD OF HEALTH omas A.McKean Director of Public Health Q:/health/wpfiles/kluskey.doc OF1HE Toy, Town of Barnstable Regulatory Services 9 sn Mpg ' Thomas F.Geiler,Director �A .q sb g �0 rEt6 A Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-8624038 Fax: 508-790-6230 Notice of Building code Violation and Order to Cease, Desist and Abate: Mr.Peter Joseph Kluskey,Jr. and all persons having notice of this order. As owner/occupant of the premises/structure located at 709 Wakeby Rd.,Marston Mills,MA Assessor's Map 028 Parcel 025 001, you are hereby notified that you are in violation of the Massachusetts State building code 780 CMR Section 3610 and are ORDERED this date March 5,2003 to: 1. CEASE AND DESIST IMMEDIATELY,all functions connected with this violation on or at the above mentioned premises. SUMMARY OF VIOLATION: 780 CMR Section 3610 Stove vented through outside wall in violation of 790 CMR Section 3610. 2. COMMENCE immediately, action to abate this violation. SUMMARY OF ACTION TO ABATE: By 12:00 noon of the day following receipt of this notice begin action to abate by: 1) contacting the Building Division to express your intention to comply 2) apply for permits to come into compliance And,if aggrieved by this notice and order,to show cause as to why you should not be required to do so,by filing an appeal with the State Building Code Appeals Board(as specified in Article 1, Section 122 of 780 CMR State Building Code)within forty-five(45)days after the service of this notice. By order, ,Q z David Mattos Local Inspector cc: COMM Fire Department CERTIFIED MAIL 7001 1940 0003 9647 3055 Q/FORMS/violatel Town of Barnstable. • Regulatory Services * BARNSTABLE, �• 9� "'ASS' Thomas F.Geiler,Director i63y. ♦0 A'E1639 i Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Notice of Zoning Ordinances Violation(s) and Order to Cease, Desist and Abate: Peter Joseph Kluskey,Jr.and all persons having notice of this order. As owner/occupant of the premises/structure located at 709 Wakeby Rd.,Marstons Mills Map 028 Parcel 025 001, you are hereby notified that you are in violation of the Town of Barnstable Zoning Ordinances and are ORDERED this date,March 5,2003 to: 1. CEASE AND DESIST IMMEDIATELY,all functions connected with this violation on or at the above mentioned premises. . SUMMARY OF VIOLATION: Violation of Town of Barnstable Zoning Ordinance Home Occupation Section 4-1.4 2. COMMENCE within seven(7)days,action to abate this violation. SUMMARY OF ACTION TO ABATE: Remove vendine machines from the premises And,if aggrieved by this notice and order,to show cause as to why you should not be required to do so,by filing an appeal with the Town Clerk of Barnstable,a Notice of Appeal(specifying the ground thereof) within thirty(30)days of the receipt of this order(in accordance with Chapter 40A Section 15 of the Massachusetts General Laws). If,at the expiration of the time allowed,action to abate this violation has not commenced,further action as the law requires will be taken. By order, ZJ Z') David Mattos Local Inspector Certified Mail 7001 1940 0003 9647 3055 _ Q/FORMS/viozonel Town of Barnstable Approved Regulatory Services Fee i Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 / Home Occupation Registration Date: Name /�1� c-liGL✓—� fJ`�s Phone#: Address: Villager Name of Business: Type of Business:'11,e 0o2, �� �� l D/ S INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation . within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector, a customary home occupation shall be permitted as of right subject to the following conditions: The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. No traffic will be generated in excess of normal residential volumes. The use does not involve the production of offensive noise,vibration, smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. There is no storage or use of toxic or hazardous materials, or flammable or explosive materials, in excess of normal household quantities. Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation, and not within the required front yard. There is no exterior storage or display of materials or equipment. There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned, agree with the a restrictions for my home occupation I am registering. Applicant: Date: 0 � L} Y ����� ��,� �. � ��� m. �n�% Miorandi, Donna From: Miorandi, Donna Sent: Friday, November 22, 2002 11:32 AM To: 'priscilla.neves@state.ma.us' Cc: McKean, Thomas; Perry, Tom Subject: Vending Machines Hi Priscilla, I am in receipt of a complaint regarding a man running a vending machine business out of his home. Since it is under 105 CMR 590.018 1 am reporting it to you. This man has many vending machines all over his property and also pieces, parts of them. It has been observed by two other health inspectors that his garage is loaded with crates of soda and they see a Pepsi truck deliver a load once a month. This is a disastrous property that has many old abandoned vehicles and many large bags of empty soda cans and much more debris. We are issuing him a warning notice to clean-up but looking to you for any further advice. Thanks again! Donna Miorandi 1 Miorandi, Donna From: Miorandi, Donna Sent: Friday, November 22, 2002 11:32 AM To: priscilla.neves@state.ma.us' Cc: McKean, Thomas; Perry, Tom Subject: Vending Machines Hi Priscilla, I am in receipt of a complaint regarding a man running a vending machine business out of his home. Since it is under 105 CMR 590.018 1 am reporting it to you. This man has many vending machines all over his property and also pieces, parts of them. It has been observed by two other health inspectors that his garage is loaded with crates of soda and they see a Pepsi truck deliver a load once a month. This is a disastrous property that has many old abandoned vehicles and many large bags of empty soda cans and much more debris. We are issuing him a warning notice to clean-up but looking to you for any further advice. Thanks again! Donna Miorandi 1 I �So cl� IA1 10-s i so dick Sa��, THE COMMONWEALTH OF MASSACHUSETTS BOA RD ,,9F HEALTH, Application is heyeby made for a Permit to Construct (C-f or Repair a Individual Sewage Disposal Systep at _5C Address ...................... Installer Address Type of Building Size Lot.Vy-?...70�9..Sq. feet Dwelling—No. of Bedrooms.......S..............................Expansion Attic 'Irz Girbage Grinder frft Z Other Distribution box Dosing t Percolation Test Results Performed by 26 l.fl.�Zern Date.... Test Pit No. V45.:�.....minutes per inch Depth of .......e'Depth-'f o ground water­,,,�.,. �14 Test Pit No,*ra/t11—.minutes ver inch Depth of Test Pit ........ Depth to ground water Description of Soil..... The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systernin accordance with the provisions of TL I'i IS 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Complian has bee ssued by the bgx,+yf health. ate Date —`-'------ o^te Date ________________ e No................_....... Fss............._............ _ THE COMMONWEALTH OF MASSACHUSETTS ,,,,---BOARD QF H EA T Applirtt#ion for Uhip anal Works Tons#rur#ilatt V erritt# Application is hereby made for a Permit to Construct ( or Repair ( ) Individual Sewage Disposal Syst .. ................. .. ................. . A.�­..�" ... ... - -------- Address .. O �C ,ryry ' � -- ...................... ................................................................................................. Installer Address J�p y�� Type of Building Size Lot.. -_`- }Y�t---...-----{-,-,:)-.Sq. feet V Dwelling—No. of Bedrooms_-_.....- ....._..•..._..__..Expansion Attic ( Garbage Grinder ►-+ aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other - - -------------------------------------------------------- 6 _____________________ ___ _ __ _ _............................ W Design Flow..•........ ....................gallons per person per day. Total daily flow.......... __ -. ..................gallons. WSeptic Tank—Liquid capacitV!.�Pgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area....._•.--.---...s . ft. Z Other Distribution box ( ) Dosing ) '-' Percolation Test Results Performed b ...................... 4". .' '_! !!' Date_.. __. . Y Test Pit No. )A/_.��.._--- minutes per inch Depth of st Pit.__._j___ �!... Depth-lo ground water..___ fG4 Test Pit No.. &: 2L,mi ch. e h of T t P't._,e�.-Q�s A Depth to round water........................ g O Description of Soil.....I -----.... =- ' C s r'! x . . •-•-•---•--•--••-•-•••-••-•---...---•-•-•••-•.............. W U Nature of Repairs or Alterations—Answer when applicable.............................................•................................................. ..---•--•••--------•••----•••---•-•-•-----•---•-•.......•---•••--•••......•---••----••.......-----•----•••••-•---------------•----••-•--•--......••----•-•-------••.•---•---•••--•-•-•-•-••--•......•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Complianc has bee sued by the bo llealth Si ed..... . ......... ........ Application Approved By........................... -.>.. ..1 . ate Application Disapproved for the following`r asons:------•..................................•--------------------•---------------------•------•-••-•....--•••----- ..•-•-•-...--••-•-•-.......--••-•-----•-•--••--•----••--•--........•---••-------•----_•------•-----••••-.--....--•.............•---•-•-=-=-------•-••-----•--•---•----•-••----•-•--•--•-....._........_. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT .............OF..... .�. �....................... Ter#ifirtt#r of f ompliatta IS TO CE IFY, Thath I dividual Sewage Disposal System constructed (_100*or Repaired ( ) by-- ... ........................................ atd Ca has been installed in accordance with" provisions of TITLE 5 of The State SanitarY Code as described in the application for.Disposal Works Construction Permit No----------------------------------------- dated.............. ............................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL NCTI N SATISFACTORY. DATE....... .............. ......0 ................................ Inspector...............I......... ...................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD: F HEA TH r� �..............OF........ •'t.0' e'- ........_. 7 ................. toMl nrk - nn #rr# n VPrlltt# Permission i _... : C _ia f ... reby granted to Constr ( or epair3 ( }.. dlvidu wage posal`cyst at No........_...... .• a.._ +�•.,' :r''' ... ................ as shown on the application for Disposal Works Construction PermittNo. �+'.�,�_\Dated 1�- - b ........----•--•-•--••.................... . 1 '- ......... bB r of Health DATE.......................................... FORM 1255 A. M. SULKIN, INC.. BOSTON raj rtff^s e Z� �9 Z At 2. r' r r l !P 9 PHILIP. WEMBERG j �RoAIr-AGcG Na: 366 Q > Ch < �`�� ANAL h�o•-fs L -T- pw 009 17 Z 82 0 5 S,° t T P�Op6S DO VI Pf7 7�r 97.3 \ u! �19, 32 � f _------------ `A=3'f,BY 99.3 S $y° 06 • H 6. 14Z) 9 g'8 , r w KleBy wet-L1 cG L (V/Slf3LE) LEGEND EXIST: G SPOT ELEVATION Ox.0 .r CERTIFIED PLOT FLAN EXISTING CONTOUR — O -- - FINISHED SPOT ELEVATION �' �'`�'�� Y FINISHED CONTOUR 0 --- APPROVED , BOARD OF HEALTH IN A ASS* DATE AGENT SCALE,/ a ` DATE 2 8G LOREDGE ENGINEER /NG Ca IN CLIENT�Z N g I CERTIFY THAT THE PROPOSED 0 ED i EGISTERE REGISTERED JOB NO. . s'g�° BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS E GINEER URVEY OR,BY� OF BARNSTABL � ASS. 17 712 MAIN STREET CH. BY= �AE ,� ,,�-a:y'HYANNIS, MAS$. SHEET'L OFi REG. LAND SURVEYOR } !ti 0 /F E/TNER 7`NE .5EP7-/C TANK, OR. n-E,ACI-+'//VG P/T ARE MORE 7 --V 1Z"SEL0JN G'OryC'RETF CORER !E S�yALL B.F OA?O&aN7- TO 4RA /✓ zx-,-" 9 J CONCRETE r 4 PVC PI PE i ILY&I' CA S T PI COVER SAIA L L 0,E 41 S E1O M/N. P/TCN CDi�ERS //v OR/VEN/A Y P1�iQ FT. ` 2 , M/N. ;A rir- GR.40E CC.) VER CLEAN SANG :..� L/494//O LE✓EL ;Y 19 DIA 2'LAYER SCHEVULA40 o��'- OF V.C. 0/f�E a v o o ;=as /"9/N.P/TGN rr. --�d d 0 OA4. - D/ST. o• o • • • • • • • • e 4p4 WASHFO 5701YE v4'PER SEPTIC TANK o • ,• +, . . . • • • BOX v • $ lot • • • • • of v e 41 p EFFECT/VE • • e • ° '' • • DL`PTt! • • + ' v o bV.45HED STONE. IS-b,-7 x 2,5 = 37,E s •Q'e. • 1 . ,� • • + . . cv , -, x /,o = /,3. //3 s a. .a • + • • • . • , • p,e•D PREC.AST SEEPAGE s I o .. • • • .• • • • ' s o _ P/T OR C-041/V. lNYE'RT ELEf/AT/ONS y90 a4-/or►y p Ez.s9,o RT.AT 8U/LD/NG 9�,a prr C•+of►c r?Y 6, T. /NYE FT. C(5EE rA&ILAT)O/V> INLET SEPTIC Ti4NK 96,E FT - j O(J7LET SEPTIC TANK Fr INLET DISTR/B /ON BOX 3° FT. GROUND atrfiTER TA9LE vT SECT/ON O'a Ol/TLETD/ST.4/�9tlT/ON_SOX 9y:$FT '/A1I LEAC/ INa Pier 93.o FT. SEN/AGE L7I3POSAL SYSTEM TABlILAT/D/V LEACH/NG P/T O/ME1v3/oN A 3 FT SCALE DE516AI CR/TER IA D/M.E+VS/oN 8 q-FT. NUM BER OF BEDROOMS 3 D/MENS/ON C — ,GARBAGE D/sPOSAL ZIN/T Now SOIL LOG TOTAL E-T1,0I > FLOh/33" G.4L./DAY SO/L TEST SOIL.L TEST*2 I SOIL TEST- NUM8cR AF :E4CN/N4 P/Tj__ ( . ^ELEI! ELE'Y. ,DATE OF SOIL TEST J k z /8 S/OELEACH/NG PER P/T 11 •l Sy'7, FT. i RESULTS /VITNESSED BY (eJ '3UTTOf�f LEACH/NG DER PIT I(3_� FT n O �� TO� PL`/tCOLATIDN RATF / AESS •` �'SvJRSo/4- PE/tCGl.IV RATE_I!><•2 -�'� M/N. 1FNCN TOTAL �EACN/NG AREA ��1 SQ. FT. � l - RESERliE AREA_ SQ. FT. �,� �� 5 0 TE s p -44 2-/ r TH O F 0e, Fie i,, SOIf 5R aF.L O . ;d WILT � �Ott n /Lt/()�S�C7/V'� /�'C o WEf P5BERG > ,aia ay V iN o No. 356 Oi �° r rEL DREDGEENG/)VEERING CO;lNC. i srEF`�`�F,;'C `L 7/2 MAIN ST., .4'Y.4NN/S, pp �3S1O N At ENS'' r` t ' Li C q, 3 f / NOGROUNt`' V,4TER ENCOCJNTE.?EO G� ENT v.4 T-`' �. �� G/?O IJN O I VA TER AT ELE�! CL'G/�'/�ie/E SHEET_ /4 � .I06 NO. .s/d . Z OF. Z i s ASSESSORS MAP: - TEST HOLE LOGS � �lee PARCEL ze Z-v--� ----- LL11 �� NOTES: . 2c-q,:j FLOOD ZONE: �dT ?�1�1.1C�1 � SO I L EVALU TOR: t �VI �+ M �7V WITNESS• !: REFERENCE- 6' � Zz.� DATE Q 1) The installation shall comply with Title V and Town of Barnstable Board of PERCGi'_AT I 0 RAi?E:.4 7, JV luj, I 11 , Health Regulations. 3I _ - \, \410 2) The installer shall verify the location of utilities, sewer inverts and septic TH- 1 --�1 TH-2 components prior to installation and setting base elevations. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. 4) This plan is not to be utilized for property line determination nor any other 1 purpose other than the proposed system installation. • ,' ,�pW (p{�y�t 5) All septic components must meet Title V specifications. � �j 6) Parking shall not be constructed over H10 septic components. LOCAT �I ON MAP �'-�� 4b' 7) The property is bounded by property comers and property lines. f C 8 The roe owner shall review design considerations to approve of total tM1�1,rj �H � ) property rtY gn design flow to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow. i'j 9) The existing leach pit(s) shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean washed sand per Title V /t _ _ 0 0 specs. �T LkwuAl O - 10)System components to be 10 feet from water line. �p .� 11) If a garbage grinder exists it is to be removed and the responsibility of the � . owner to ensure such. y .: P T I }.. .--.SYSTEM DESIGN 12)The existing well is to be abandoned and Barnstable Town water service is to a ;, be tied into the dwelling. Connection must meet supplier specifications. c FLOW ESTIMATE BEDROOMS AT IO GAL/DAY/BEDROOM - GAL/DAY SEPT I.. TANK CT- ) '530C-AL/DAY x 2 DAYS - 660 GAL - USE j�n�GALLON SEPTIC TANK CC 611W Ex15Ti�!t COOC� SOIL ABSORPTION SYSTEM z -7- tk) _ 4 I 'PIT' ' y�# at'�' > - o o Its Z C -t 1�j X Z.Ys J� .;: SIDE AREA: Z� p1i` '. . �' �. 90TTOM AREA: - a G � s SEPTIC, SYSTEM SECT I ON01 Y I q2, A R D- tD00 GAL I SEPTIC TANK �' -1 'DDO f7" I 7� i l SITE AND SEWAGE PLAN t p., LOCAT I ON : u f olI p . _ I PREPARED FOR : �j- '.7� SFX;r11 G (V4TkLWlb1) _ . d SCALE: W DAV I D B . MASON R5 DATE: 23 DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA W DATE HEALTH AGENT ( 508) 833-2 177