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Home My WebLink About1733 OST.-W.BARN. RD - Health 33 ®sterville West Barnstable Road )128-036 West Barnstabi i ' f r Commonwealth of Massachusetts IoZg—Oco w Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; 1733 Osterville-W Barnstable Road Property Address , Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020' page. Cityrrown 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. Inspector Information c5l 4r.- on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road OkA Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this'inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails �2�- 0 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �- -. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r G � 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: Please read:the bottom of the first page of this report. This statement is from the Ma. DEP. This home was inspected under the Ma. DEP and The Town of Barnstable's guidelines. This four bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding 2 leaching pits with stone. At the time of the inspection the liquid level was 1' below invert and no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 1733 Osterville-V\l Barnstable Road Property Address Trombley Realty'gust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c� Commonwealth of Massachusetts �w ,tip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes 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? ® I;] Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 t Commonwealth of Massachusetts Itirp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is West Barnstable MA 02668 07/18/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System (Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage Well water 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts w Title 5 Official Inspection Form +_ lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments h u � 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Inspector Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons gallons How was quantity pumped determined? drivers est Reason for pumping: maint t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form + il; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: Second leach pit installed 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 23" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10 plus feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and it came freely t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal list age:ge: years , Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the baffle was in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 1733 Cisterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is West Barnstable MA 02668 07/18/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach co of current pumping contract(required). Is co attached? Yes N PY p p 9 copy ❑ ❑ o 9. 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts _ ,� Title 5 Official Inspection Form r iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: Two ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is West Barnstable MA 02668 07/18/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of tl-e inspection the liquid level was 1' below invert and no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of I quid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts k - -p Title 5 Official Inspection Form Subsurface Sewage Disp osal posal System Form Not for or Voluntary Assessments �:t V" 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is West Barnstable required for every MA 02668 07/18/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks 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 ell r S 4 B 0 O A B A O1 35,711 16•4„ 3 2 25' 17' 3 26'5' 28' 4 32' 34' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is required for every West Barnstable MA 02668 07/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 18 plus feetfeet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts �- -. Title 5 Official Inspection Form 111 �1�) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1733 Osterville-W Barnstable Road Property Address Trombley Realty Trust Dated 8/24/99 Owner Owner's Name information is West Barnstable MA 02668 07/18/2020 required for every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspecto-Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5.completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For,15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 rn J ✓ --O- p Fee----� ------- No.to - BOARD OF HEALTH TOWN OF BARNSTABLE r Zpp[ication forlVell Congtruction Permit Application is hereb made for permit to Construc ( kAlter ( ), or Repair ( )an individual Well at: --------------.--- Location — Address Assessors Map and Parcel --- �T40I � t- Owner ju i��J� — Address Dd Installer — Driller Address Type of Building �, �+ � L Dwelling--- 2---- D(�-------- � Oww Other - Type of Buildingj------------ ------- No. of Persons---------------------------------------- Type of Well -- Purpose of Well--------- ---------______---___-- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The. Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate ..of Compliance has been issued by the Board of Health. Signe ! ��/�i' —- ----- — ----— ----- d e Application Approved B -- G"v — -- pp pp }' date Application Disapproved for the following reaso — --------— ------—- —— - ----- -- — - ?� — date o -- --- Issued-- — = -- Permit No.__---- ---- ------------------- date BOARD OF HEALTH Lt m TOWN OF BARNSTABLE C ertif irate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by------------- ---- - --- ----------------------------------------------------------- --- Installer at- ---- —--- ---- —------ ---- —--------------- -- -- ---- -- has been installed in accordance with the provisions of the Town of Barnstable B d of H lth P ' to Well Protection Regulation as described in the application for Well Construction Permit No 6 red------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------— - — —-- Inspector----------------------------------——-----—-- No.C � Fee- r i BOARD OF HEALTH TOWN. -. OF BARNSTABLE ApAkationArlVe[I CootructionPermit Application is e =WIP ermit o Constr ct ( Alter ( ), or Repair ( )an individual Well at: - ' . � ` Location - Address Assessors Map-and Parcel 33 'p Owner — Address Installer — Driller Address Type of Building -� OU�nS /UAL. A t, L �„vW Dwelling -- ---=--------------------- Other - Type of Building--------------------- No. of Persons------------- --- ---=----------- � ' Type of Well -= --------- -- - Capacity--------------------- � Purpose of Well'------------ -- - w Agreement: . . The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Ir Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed - ��' - ---- - -- -- Application Approved,By ! — - date Application Disapproved for the following reaso •—=------- - - ---- - ---— ----- -- ---�--' '— — —- ----_--'—_--L_--_ --- --- -------te -- te Permit N O Issu — -/ed - - --- ---— --- - date l BOARD OF HEA`LTH`' ` 1 M (—'Tst,2 f D TOWN O"F__BARNSTAB LE Certificate ®f Compliance a _ - --THIS"IS T_O�CERTIFY, That the Individual Well, on'structed ( ) Altered ( ), or Repaired ( ) Installer- ' at --- has been installed in accordance with the provisions of the Town of Barnstable Bad of He lth o Well Protection -- -"-- Regulation as described in the application for Well,Construction.,Permit No. ------ --- - 7et d------ ----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT`THE WELL SYSTEM WILL FUNCTION SATISFACTORY... . . • `. : DATE--------- -Inspector------------------------------ -------------- BOARD OF HEALTH } TOWN OF BARNSTABLE 50 r vell on5truct ion Permit No. Fee---------------- Permission is hereby granted to.Cons r' ( ),.Alter ( ), o . Repair ) n dividu I - - _ -- ------- ------------- t� as shown on the application for a Well Constructionit No.-— —-- - Dated- --------------------------- r U Board)Of Health DATE - f .. ASSESSORS MAP NO: ' No...Y.1 en_2n i.,Y. PARCEL NO: — d- T� Fm:s....24:5 . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ....... .............. .---.........OF..........................._...._........._...---•--.... Applira#ion for Biiipaaal Works Tonotrnrtiun amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .... 1.L ......._os��.fl.s...... �,rt i3Ankulah/��....................`'-�5.. .............................. Location-Address or Lot No. ...........Z t_...... ............................................ 1.'? ......o 'Eec�us�� Owner Address a }��'�"� ............�° .,5L ............................. .....s T'n............. s/�► o c�,l�l Install r Address Type of Building Size Lot...41av o�.....Sq. feet Dwelling—No. of Bedrooms......-..................................Expansion Attic ( ) Garbage Grinder 4c{ aOther—Type of Building ............................ No. of persons__--.__-ate................ Showers ( ) — Cafeteria ( ) P4Other fixtures --------------------------------------------------------••••......•-••-•......-••-•---- W Design Flow............................................gallons per person per day. Total daily flow.......................................... Ilons. WSeptic Tank—Liquid capacity.).Q.c.vgallons Length_........... Width..a`�......... Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................. Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.C1.4v__.._.. Depth below inlet..6-------------- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..........................•----•-----•--------•----------•--••••-...-----• Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' / ----------------------------------------- •-------------- -•---.........------..----------------------•-•-----------......... Description of Soil sate+^ .S.Sab..Sc��.�...........a.---..5l v'Q4 a 1 �-------------------------------------•----------•-•--- x W U Nature of Repairs or Alterations—Answer when applicable---------1 .0_S2.S._ ts�t.:_��.......I..�._e +k ......P.1I. .. ...-----•---•--••--•----•-•................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of H"HE:, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by theboard of health.Signed-•-• \--- -- •-- 1c/Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons------------------------------------------------------------------------------------------------------------•••-- .....---•---------------•-•-------•-•---......_..-•--------••------------....------------....--------•---••--•-------•---••-•--••••----•---•-----•-•-•--------•-••......•-----••.--••••-•------------- Date PermitNo...... ....................... Issued--------•------•-----................................. Date Fmm.....7J`'1--. '::... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...----- . .........................OF...................................................._..... , ppliratiun for Disposal Works Tonstrudion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...................................•----•------------•--•--...--------..._•-•-•-•---••-••--•...... ------•--.......-----------••-•-••----......•--•-----••--•--------•-•......--••--......•-•......_. Location-Address or Lot No. ......................—.......................................................................... _...................--•---•-•-----...-•--•----•••.............----...._......--•--.........-••--•. Owner Address W Installer Address Q Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ..................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter--._.-_..___-_-- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ ,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.___-_-___-_-__--___-. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------_................ a ..•••-------••-•-•-•--------•--•-••-...-•--••••-----•-•-•..........•--•----......-•----------------•......................................................... 0 Description of Soil........................................................................................................................................................................ U ••••••-----------•----••-•----•-•-••--•-••-••--•------••-•--••-•----•-••----••---••...............•-••-••-•------•-•--••-•-••---•----•-•-•-•-•.......---•-----•--•---•-•-------•----•••-••-------------- 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 TT;, '5 of the State Sanitary Code.— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ................................ Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons-------------------------------------------------------------•--------------------------•---••---••----•--------- --•-•---•-••--••................••---•-••--••---••••--••----••--••--.....--••--•-•-...----••---•---•-----------•---•-••--•-•----•-•---•--•-•-••-•-•--•---•••-------•----••-•--------•-•-•--•-••-••----- Q� Date PermitNo.....4.__,7 - -y....................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... .....OF....... ........................................ Trrtifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at ..._ a. - =� -••--•-----•.................... has been installed in accordance with the provisions of T T T iE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit X1.1_/............... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT 'SHE SYSTEM WILL FLWCJION SATISFACTORY. ' -�� Inspecto`t ..�.... DATE.......................... '�I Co THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF............... ....... >?. ehrrxJg4f_y( -----..................................... .?- �- �/ 7 EE...No. F ......:1............. Disposal�Works Tunutrnr#ion rrmit Permission is hereby granted........PA'r...T... •--... .._..... to Constr t (�) or Re air ) an In'd�iv-i�dr�ual SewageSystem atNO.••-•a .......;..-------- ........................� ." "' ' �'f�' Z.':; _..-----------------------------------------------------------------------------------------------Street as shown on the application for Disposal Works Construction Permit No�)=J ._ ---- Dated..._L,!_-:.f .::__..�F..7....... ...... '-_- ;...---------------••-•----•.----_ dd V J DATE........�'/.-"--�-�•-=�---D•---?--------------------------- _. _... Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ` ` THE COMMONWEALTH OF MASSACHUSETTS ® BOARD OF HEALTH TOWN....................OF........BARNSTABLE .�� #11ratiun for Di �u�ttl urk� Cun��rixr#tun �erni# pplicatton is hereby made for a Permit to Construct ( g) or Repair ( ) an Individual Sewage Disposal System at: ............... »WEST BARNSTABLE M. AM 128 LOT 9 ------------•................-- _............_..._...-•-....---•••••••••...-•--••--•--.....-•----.............................-•-• Loc io -Address or Lot No. ................»..»»»». .......------ *---------- -------- •------...--------------- ....... ......--.------------•-• ........................... r I Address a nerl Installer Address 43 560 Type of Building Size Lot._.__..!...................Sq. feet U � 3Dwelling—No. of Bedrooms.......... ..........Expansion Attic ( ) Garbage Grinder (He) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------••-•------• Design Flow..........._55..........................gallons per person per day. Total daily flow............................................W p Eff WSeptic Tank—Liquid ca.pacity_10 0 Ogallons Length..g i_._....._ Width..4 z_....._. Diameter________________ De th_...4....._..._.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area........_.._.......sq. ft. 3 Seepage Pit No.......I........... Diameter......!®.........Depth below inlet........ Total leaching area... q. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by....._.BAXTER.._&.... NONE,� Test Pit No. 1................minutes per inch Depth of Test Plt_._...._._......_. Depth to ground water.... r3� Test Pit No. 2------- .......minutes per inch Depth of Test Pit......4............ Depth to ground water...NONE a' -------•-------------------------•----......-•----------......---••-•---.........--•-••.....--••••-•..............---•.....--••-•................. ...._. 0 Description of Soil......0--2 ' LOAM & SUB SOIL 2-11 ' SAND & STONES, SOME FINES •................ W � ,_.. .-- ----•-•-••----------•••-•------• -•--.. ....--• ......-- •------• •------- -----•••----....----• ----••-••-••••........•---.._...... ........---•---------------- -------------------•------------------•------......----•-------••----------•-•----•----------------...---••-------•---------•--•------------•-----.....------.............. U Nature of Repairs or Alterations—Answer when applicable...__..SEE ATTACHED PLANS .._......--•---.....----•----------------•--••-•-••-----•.......---------•----------.............------•••-------.......--------.........--•-........... Agreement:- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITi.i� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has n isd by the board'ohea igned. . _.. ...... -•--------------- ...................... ------------. ................. Application Approved By............ . .=_ ..•-•isVie,y ••..---• . .....--•--.._..Date Application Disapproved for the following reasons:.............................................................._.......---- .......-_____. ....................•---......----...........---••-•-•---.........................................---..............--•--•--•--•--•---------....------•-•-------•-••-------•-----....-----.....--••--..... Date PermitNo..... - ......................... Issued....................................................... Date or THE COMMONWEALTH OF MASSACHUSETTS " --BOARD OF HEALTH ..........OF........BARNSTABLE t lirtt#in A '�~�� n for r �9t,�pnlittl Works Tnns#rnr#inn Permit T Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: •.............»OS ' VIL „_---»WEST Bll<RNSTABLEo• AM 128 LOT .9 ----••-------------------------•--•-•---••---...-----............----...._._......-----•.....-••- Lo�c�a}t_io.{{n-Address or Lot No. : L'c.�lSCr. Wcaner �r!•------------------------ Address a _._....-•---- �..................... ............................................ .... Installer .._..._. Address 43 560 Type of Building Size Lot....... ...................Sq. feet Dwelling—No. of Bedrooms...............3._.____....__.._______.___Expansion Attic ( ) Garbage Grinder (ric) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -----------------------------------------------•-----.._...---.....-------•••-••--•••-- 30 w Design Flow............. ..............................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity_1U00gallons Length__M........ Width._4�___.___ Diameter________________ Depth.4--•Eff. x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area__._..._____.......sq. ft. Seepage Pit No........I...... ..... Diameter......l0........ Depth below inlet........ Total leaching ar'ea... ..........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.._._..BAXTER & NYE Date...._7 19/8 5 -----•---..................... --------•- a Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water_.-NONE rz� Test Pit No. 2....... _______minutes per inch Depth of Test Pit......4........... Depth to ground water.._.NONE a' •--------------------------------------------------•-----•-----•--------------......._..-•-•---•----.................................... O Description of Soil......:72Z' LOAM & SUB SOIL 2-11 ' SAND & STONES, SOME 1CINES x •-----------------------••-•-••--- •--•••••••-•......._....••-_•--••- U •-•••-•••-•...............:.•••••---•-•--•------••••••--•-•-•••...-•-•---•---••--•-•...•----------•---•-----•-----••-•-•-•-••-•--•••-•--•••-•--.....-•-•...•-••-•---•--•...--••-•---•--•-•-•••--•----•-- w U Nature of Repairs or Alterations—Answer when applicable_.___-SEE ATTACHED PLANS ATTACHED ----•- S ..•• ---r••-•-•...••••••----•-•••.....-•-••--••--•._..._..-••-•--••--••------•-------•••....._••-•--•••••................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I'LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has n isskied by the board oj hea tgned.... Application Approved B Date PP PP Y :.".V!.�Q:. ---•-- .... Date Application Disapproved for the following reasons:........................................................................... ................................... ..---••----•--•------•--•------------------------------------------------•-------.........---------......._....._...----•--....._..--------••------------------------•-------------..._.... Permit N_o........ ��.._ .................................... Issued--------------------------•--_........----Dan...... Date ..... — _---_, THE COMMONWEALTH OF MASSACHUSETTS - r BOARD OF HEALTH TOWN BARNSTABLE OF..................................................................................... y Ter#ifirtt#le of Tomplittnrr THIS J_� TO CERTIFY That the Individual Sewage Disposal System constructed (X) or Repaired ( ) y...- �..... .... LOT 9 AM 128 OSTERVILLE, WEI&11leMARNSTABBE ROAD at.......................................................................... has been installed in accordance with the provisions of TITLE- 5 of The S a Sanitary Code as described in the application for Disposal,Works Construction Permit No.......�='6�_'__ dated........1. .2. � __C................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS R ED AS A GIJ RANTEE THAT THE SYSTEM WILL FpqrTION SATISFACTORY. f DATE:. _- -, ..... ....... Inspector---•---•----TP-7--------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........TOWN OF.......BARNSTABLE .......................... N0 ......... FEE.......?t� ........... Disposal Worku Tono#rwtion Permit Permissionis hereby granted........................................................................................--._.:-::. .._.__......._._..._..._................. to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at No.......LOT... _...: ...a:_U---OSTERVTLLE -:_WEST _BARNSTABLE ROAD +' • •••-•-•--•--•----••......::. ........ 1 - Street ] �, /!�� as shown on the application for Disposal ��'orla Construction Permit No..................... Dated.._.._.� . ..__...._......___._.... DATE------------------------- -------4----------- Board of Health �J--�"----- . ----�--•---- ' 7..�' a a�s� II FORM 30 Hew HOBBS&WARREN'"" THE COMMONWEALTH OF MASSACHUSETTS B RMOH(E LTH CI Y/TOWN DE ARTMENT� DDRESS GSM 50y`0 e TELEPHONE Address ___-YVi_I, �V-A�✓__it_ cupant(%. oI aO Floor Apartment No. __ No.of Occupants_ No. of Habitable Rooms No.Sleeping Rooms_/___ No.dwelling or rooming units__ No.Stories _ ) 1° /�, Name and address of ownep/,_&yl ._A4J;J�Y_�—t-�(/Yj'1�?��1 1 QA+e_t 11P to .bot l �f Remarks Reg. Vi�� YARD Out Bld s.: Fences: �� Garbage and Rubbish Containers: Drainage v ' Infestation Rats or other: 4 STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall, Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box.- Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom —Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink kWOF Stove Bathing,Toilet Facil: Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSP C ONT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIE INSPECTOR TITLE d & , ww� DATE V TIME 1 A.M. P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. , ♦ 'Hill. :< i.. a. { h, [�� ir" '!` r - 17 :r '1 e.� ' 4' • r•. .. 1' . 1+` _. . 7. _ 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in reside,-itial premises, shali be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. =ailure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violaticn(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410 180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of -.05 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and CDntrol, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or elec--rical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the healt-i or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. f ;; TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In �- j ,` Out Owner Tenant Cam . Address 3 Address I 1 Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use G ;C 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing N 18. Driveway Width 19. Number of Tenants Observed 9— So ��— PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) 2 Number of Persons Allowed (max) (� Person(s) Interviewed Inspector c (�- 6j, If Public Building such as Store or Hotel/Motel specify here Date �` d To Whom It May Concern: a ;7 , voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health(Agent or Health Inspector) to inspect my dwelling unit located at 1q 36( c,) vjl� U, u; � � in accordance (House#, [Apt\Unit#if applicable], street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on - a S ao 16 I hereby authorize and name (Date of inspection) �K to be my tenant representative for the (Occupan(r presentative) purpose of this inspection.� j,��ly�p ��/��/ is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) upants Signature \ a e Occupants Representative Signature \ Date , Q:\Rental Ordinance\inspection pennission 2.doc l ` FOM30 &w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H CIT W I ^ _ I DEPARTME 4— ADDRESS G,,M S By`ow TELEPHOV -33 Address----:1-7 ® _ Occupant Floor Apartment No. No.of Occupants— No. of Habitable Rooms No.Sleeping Rooms--I—. No. dwelling or rooming units_ N Stories - Name and address of owner 54� � Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall', Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: 11110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen ; Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: StsWks, FI ts,Safeties: Kitchen Facilities in 8tKe Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION ORT IS SIGNED AND CERTIF"UNDEHE PAINS AND PENALTIES OF P INSPECTOR TITLE f A.M. DATE "(C); TIME ` P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. l t , u o 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the. occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to.p�avide a.supply of water sufficient in quantity, pressure and temperature, both hot and cold,•to meet the-ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410..190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. 3 No............. Fa$.... .� ...:... f►PPf?OV E D Barnstable Conservation DepartMentHE COMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH Oato TOWN OF BARNSTABLE S Appliratinn for Biripatinl Wnrk,6 Tontitrur#inn_ runtit Application is hereby made for a Permit to Construct ( ) or Rcpair ( f1j an Individual Sewage Disposal System at: ' a im hires or Lot No. -.- ---- _-.. .......... . •-----••- --•••------... ._.......- WcnC �7y (,, C! •sF4yl-.7.- _�._!_ �d.. �„1 /=q/1// ... a .'.......... .... ............................ } 7�! (V! 7 Installer Address/ Q Type o Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms_________12____________________ ___________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Oth r .fixtures _-------------- --'•--------.... . W Design Flow......P ..............................gallons per person per day. Total daily flow----- 3 ..........................gallons. 1:4 Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ Disposal Trench--No. .................... Width.................... .rotal Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.............-............................................................ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' -------------------------------••-••-•-•--•---------------..-.-..---•--.--.......------•-•.--.......-----....................---•--•-----------•--•- 0 Description of Soil............... .........................._.._._._....... x ------------------•••---•-•----•-•---••. ••--• .........-........................................ -----........_.....---....-•-•---•--••-••-----•-••-•••----------•--•---............... 0 Nature of Repairs o Alteratio s—An wer en p icable.1167, ---------� '.AAV ...� .. ®_� do , Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia been 'ssued he b a�I of ealt --J Signed .........._ ........... ...... ........................... ............................. ....�....--tee................. Application Approved By .............. � .. �.......................... ............................................. ...../...,..L,,:L.�-..gOL Dare Application Disapproved for the following reasons: ................................. . .................................._.... ........................................ ...... __ .................................................................................................................................... ...................Date.......--......... Permit No. ......c..... .. . ............................... Issued .................................................................... Dace l .�.-.1•,.`�,...^.-...-r-�-..`...-..-„!--'�„r "-�-....-�--'•cdrti!"`''`�.+ti-'�-..,..�.r..,�,,a..,J'�,.i.i ��-,.,.,� .a;y .%r--�. � V„a,—. ..,_ ..r- �; y y..... - i No........................ FEB .��........ i THE COMMONWEALTH OF MASSACHUSETTS f e y �- p,YBOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diaipooul Wi orbi Tattitrurtion Verntit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System /�' .3t .. Lo'c;itinn �ddn'ss or Lot No. dd ! nstaller Address 0 V d Type of Building Size Lot............................Sq. feet UDwelling—No, of Bedrooms._.......2......................_...Expansion Attic ( ) Garbage Grinder ( ) pal Other—Type of Building ............................ No. of persons......................... Showers ( ) — Cafeteria ( ) a' Other fixtures ............................... . . d - -• ......................... ... ......... ...... . .... W Design Flow...... /o...........................gallons per person per day. Total daily flow-.-.._�_.3.�--.......--_............gallons. WSeptic Tank—Liquid capacity............gallons 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..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 04 ,-� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G74 Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................ P+ •-•-•---.....••••----•--•••--•--•---•-•-•--•-•••-••-•••-••.............•------..........-••••-•--•••......................................................... ODescription of Soil...................................................--•-•-•--.......----------------------------•-------------••----•---•----------•---•----------••-••............---•- W rJ --............. ••------------------ ---•------------------------------------------------------------------- •------------------------------------------------------------- ••-----•---••---.-.-------.-.... W Nature of Repairs or Alterations—Answer when applicable_/ 14 4r �_�...._._ �' ._ J� ....:.rU ..__ ....5�'�:•.. ...... o �x�s /� .. X�6--------------------------------------------------------------•-•-----...............------......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha4s been issued by b�y tt(h_�,e bbb and of health. J �' Signed ............ .......................... ......7.....-.......f... / -,/. ........................................ Dare Application Approved By ............. ..`��.. ................................................................... .... ...../......../..�...�...9�l/ . Dare Application Disapproved for the following reasons: ....................................................... ............................................................................. MCC PermitNo. ..- :�7.................................... Issued .................................................................... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Ginplianre THIS IS TO CE .TIEY, That the Individu -1 Sewa e Disposal System constructed ( ) or Repaired rr� 1� .� by .......................... - - ..... ...... .. / ./ .�.'�... _... =..... ............................ I Eli at ..................._............................... .. ...../.-----(//.) ._(/.L..f...L-. /_�.l. Js�, .<a./..T-.-- /....... 1........................- `'..�. has been installed in accordance with the provisions of TI I'hE 5 f The State Environmental 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 FUNCTION SATISFACTORY. DATE . _................ .. .�.......� '.. _. ...... Inspector .........r...- ..................:...........................................- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE...- .................. din potty or��nj'` Tonotrutt t rantit Permission is hereby grant�..._.-�/;!A. t'�1 �'��>/ � �' ... to Construct ( ) or Repair ( ) an It Sewage Dis 2osal/�S stem at No. --.......... 7.-�.� D�'��`9C l� ......O..v``'l�.-1_. :y/?9..1 ..� .... •••••- _. • street qq as shown on the application for Disposal Works Construction Permit No.1.�n/.3_ Dated----- 9........... Board of Health DATE.............. - 9 ------------••-•-- --- FORM 36508 HOBBS r!<WARREN.INC..PUBLISHERS i ' c G OF X4ySTABLE y LOCATION 6 c,Q'ns i,o ya. t SEWAGE VILLAGE ✓®J J�IS ASSESSOR'S MAP G LOT INSTALLER'S NAME & PHONE NO.� f Ll4/.��/Ci/JU 7)�' SEPTIC TANK CAPACITY C LEACHING FACILITY:(type) (sue) NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No__� � x L (-j " G, TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION f Date t Time: In Out Owner Tenant Address �� Address Compliange Remarks or Regulation# Yes AO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities Fir ► - -- 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation -�-- 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use - 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing on 18. Driveway Width ti 19. Number of Tenants Observed PART II 37. 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"� 4:: � � .�,.. - F'. � Parcel Detail Page 1 of 3 g x ,(�� a e " L j e_9 e 1AS �y - Logged in As: Parcel cel Detail Friday, Mar( Parcel Lookup Parcel Info Parcel ID 1 28 036 I Developer 9 — -- - - — _ — -- ------ Lot I— - Location 1733 OSTRVILLE-W.BARNSTABLE RD Pri Frontage, Sec Road I Sec ' Frontage -_ Village WEST BARNSTABLE I Fire District,W BARNSTABLE Sewer Acct I Road Index '1 188 Interactive _ r MaP - Owner Info Owner TROMBLEY, LEON T&SANDRA L Co-Owner TROMBLEY REALTY TRUST Streets '1733 OST W BARNS RD Street2 y —.__ -- - zip '02668 Country US city WEST BARNSTABLE, state MA i -- - Land Info Acres 1.00 1 Use Single Fam MDL-01 I Zoning j Nghbd 0105 Topography Above Street �I Road Paved Utilities Gas,Well,Septic Location Construction Info Building 1 of 1 Year 1986 able/Hip oo Rf_ `— bo P G 1 Cla ard Built __ Struct -- --- __ ._ . Wall Ext _ ---_---____ I Effect Roof AC . 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