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Home My WebLink About0134 PINE STREET - Health 134 PINE STREET WEST BARNSTABLE _ A = 153 025 ' \ a r o i v f - Commonwealth of Massachusetts3� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �✓ 134 Pine St Property Address Bank Owned _ Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 page. City/Town State Zip Code Date of Inspection r�7 ' r+ 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. A. General Information s� la oS�f 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 16.000).The system: ® Passes , ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluatio y the Local Approving Authority 12-12-16 In pector'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. Et5ins-3/13 Title 5 Official Inspection Form: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 A: a% 134 Pine St t 'J" Property Address Bank Owned Owner''' Owner's Name information is required"for every W. Barnstable E'* MA 02668 12-12-16 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be t 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. c ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts ^+ f Title 5 Official Inspection Fora � I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due i to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i Commonwealth of Massachusetts :aa Title 5 official Form Inspection f p � l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 134 Pine St Property Address Bank Owned Owner Owner's Name information is W Barnstable + required for every MA 02668 12-12-16 page: City/Town 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less r than day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposmi Cystem•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form .N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - :a=1 Title 5 Official Inspection Forme I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Js!, 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 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? El ® 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? ® ❑ • Y P � 9 , ® ❑ " 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): 5 ' Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Official Inspection Form!Subsurface Sewage Dispospi System•Page 6 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Fora fI ' ,�14 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 page. CityfTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well g ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts .a=1 Title 5 Official Inspection Form f ' If,., Subsurface Sewage Disposal System Form Not for Voluntary Assessments ' v% s!, 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W.Barnstable MA 02668 12-12-16 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: N/A 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 F ❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 'I I Commonwealth of Massachusetts Title 5 Official Inspection Fora � I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 72"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 64"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 gal Sludge depth: 12" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts s r Title 5 Official Inspection Form V Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable :; MA 02668 12-12-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Septic Tank (cont.) F• i Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1 Distance from top of scum to top of outlet tee'or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete metal fiberglass I❑ ❑ ❑ I ass ❑ polyethylene lene El (explain): 9 p Y Y ( P ) 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•3/13 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts :a=1 Title 5 official Inspection Form R' 114 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form �1;�i Subsurface sewage Disposal System Form -Not for Voluntary Assessments a� 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 page. City/Town 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.): Good condition with water at working level and no sign of back-up from field. I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i Commonwealth of Massachusetts =1 Title 5 official Inspection Form f, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 7-Infiltrators ❑ 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.): Infiltrator leach field in good working order and empty at inspection with no sign of back-up into d-box or surrounding stone. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �.l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4S a� 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �If,-I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 134 Pine St Property Address Bank Owned Owner Owner's Name information is required for every W. Barnstable MA 02668 12-12-16 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 bLl Oet t t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - ,a=1 Title 5 Official Inspection Forme f ' '�-I Subsurface Sewage Disposal System Form Notfor Voluntary Assessments ' {y a' 134 Pine St L J' Property Address , Bank Owned Owner Owner's Name information is Barnstable MA 02668 12-12-16 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells fo Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: 1 ® 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: 4 ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts az, l Title 5 Official Inspection Form �A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 134 Pine St Property Address Bank Owned Owner Owner's Name information is W. Barnstable MA 02668 12-12-16 required for every 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 NOTE TO FILE: 134 PINE STREET, WEST BARNSTABLE M/P 153-025 Wed 3/25/15 Lisa, American Tax Reporting, 214-731-7686, called to see if there were any open violations, any issues, any problems. Wed 3/25/15 Slc left a voice message for Lisa, 214-731-7686. No open violations or problems. Back in 2002, it was rented to a tenant and had some maintenance issues which were resolved. The property has well water. Other than that, nothing to note. SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY _E Complete iteIms 1,2,and 3.Also complete eived b Please Print Clearly) B. Date f D livery item 4 if Restricted Delivery is desired. 6 7 ■ Print your name and address on the reverse so that we can return the card to you. C. Si X nature ■ Attach this card to the back of the mailpiece, ❑Agent or on the front if space permits. ❑Addressee D. Is a ivery address different from item 1? El Yes 1., Article Addressed to: If YES,enter delivery address below: ❑No Robe,-+, 1-3 ne 3.`S ice Type ®Z Wo 0 ertified Mail ❑ xpress Mail ❑ Registered Veturn Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 7001 0320 0003 6695 5 9 8 4 ) 4. Restricted Delivery?(Extra Fee) ❑Yes.,1, 2. Article Number(Copy from service label) ;; li 1 ; ' 1i94+ "•iij ii ;tt PS Form 3811,July 1999 , j I Domestic Return Receipt 102595-99-M-1789 cow JH UNITED STATESPOSTAL $ER P� G, g12 tages&�"e-e-P-aid S_P o tntLQt��4 � • Sender: Please print your name, address, and ZIP+4 in this box • Public HBO Men Town of Ba=kbls Hyann1s,Massachusetts 02601 I: lilt II:IIIIfil��il�,Et>>Ili,i��ltl�:ifs,�l+�,l{s3�a{��i:i1�:�� G I � °; OFF4. C � AL USE. Ln Postage $ `31 Ln 01 YD Certified Fee -a � ° 30 �� PN' nark \ Return Receipt Fee 9 ` ^ dre \(� (Endorsement Required) t3 Restricted Delivery Fee Eb (Endorsement Required) C3 Total Postage&Fees Is l 2ru M Sent To 'T O -------------°i----- Street,Apt.No.; C3 or PO Box No. 3!l �' 5� - ______- t----- O City,State,ZIP+4 �' w. &lirK s c,��Q f�l OZ-CI?�o p Certified Mail Provides: n A mailing receipt B A unique identifier for your mailpiece - o A signature upon delivery o A record of delivery kept by the Postal Service for two years Important Reminders: r n Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. 13 Certified Mail is not available for any class of international mail. o NO INSURANCI<.CCOVERAGE IS PROVIDED with Certified Mail. For valuables,please bonsider Insured or Registered Mail. - c 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 I.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. 4 AA�,/ - 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 label with postage and mail. IMPORTANT:Save this receipt'and present it when making an inquiry'.- 9 PS Form 3800;January 2001(Reverse) 102595-01-M-1049 1 - �pF THE lQ� Town of Barnstable Regulatory Services •ARNSTABLE, 9� 9MMASS; Thomas F. Geiler, Director ArE°N1°�A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health September 5, 2002 Robert J. Dube 134 Pine Street West Barnstable, MA 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 134 Pine Street, West Barnstable was inspected on September 5, 2002 by Saris White, Health Inspector for the Town of Barnstable because of a complaint. The following violations of the State Sanitary Code were observed: 410.190 - Temperature in shower exceeds 130' F. 410.202 - Water heater is not vented to chimney or outdoors. 410.280 - Excessive amounts of condensation observed in bathroom. Bathroom mechanical ventilation system does not appear to be operational when turned on. 410.351(a) - Hot water heater and shower leaking. Toilet runs even without use. 410.500 - Ceiling tiles in hallway and laundry room missing, and water damaged. 410.501(c) - During rainy periods, storage closet in bedroom floods. 410.550(c) - Mole and mouse feces observed in apartment. This indicates a possible infestation of rodents. You are directed to correct the above listed violations within fourteen (14) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, this violation must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than$500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OF THE BOARD OF HEALTH omas A. McKean Director of Public Health cc: Gloria Urenas, Building Dept. Patricia Giza, tenant Town of Barnstable WP O " Regulatory Services « snxxsraeLe, �$ .•0q Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 Office: 508-862-4038 Fax: 508-790-6230 September 4, 2002 Robert Dube 134 Pine Street W.Bamstable, MA 02668 RE: Illegal Apartment Map/Parcel: 153-025 Dear Property Owner: A review of our records,including the permitting history of 134 Pine Street, as well as Zoning Board of Appeals records indicate that the use of that address as anything other than that of a single-family home is illegal. You are hereby ordered to discontinue the use of the above-referenced property as it is now being used and restore it to a single-family home. You are to accomplish this work and notify this office to inspect within fourteen (14) days of receipt of this letter. A building permit must be applied for to redesign the layout to accommodate the conversion. You must do this before you make any changes. You have the right to appeal this decision. If you so choose, we will be more than happy to help you. If we do not hear from you within the 14 days, we will be forced to seek criminal action against you. Very truly yours, Gloria M. Urenas Zoning Enforcement Officer GMU/lb Q020904b FORM30 I-IOW HOBBS&WARREN'm THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN J J f W b DEPARTMENT ADDRESS 1) ry //(/ TELEPHONE Address � 't_• --_ 5•% Occupant_ rc,_6t7.�t Floor Apartment No. _. No. of Occupants__ Z• No.of Habitable Rooms_ _ _ No.Sleeping Rooms No.dwelling or rooming units- No.Stories Name and address of ownerp - "f 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: low't' d��-s� s ,r4cc c-Ir,r" c-H Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . 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 X 410 21 t> Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 of a er Faci " , Sup.Ten.,Gas, Oil, Elect.: Z° I rv,�, � .�, r., 1 +, �// 3s/(A) Stacks, Flues,Vents,Safeties: F, �„r. .,. 1 �;• e_ „ ,f �_„k, �!!p 7•02 Kitchen Facilities Sink Stove tBathing,ToiletFacik Vent., Plumb.,Sanit'n.: p't �,� tc,e .t.sc. c . ;7c�t,4,\ �t;f �,s, � ;;:,. y1V 2- Wash Basin, Shower or Tub: � �k=„� siie,%«y �alP,�{' dc„.a >t3c;" u:,.i,u1"" t11C tgo, nfestatio� Rats, Mice, Roaches or Other: IJt,i s + M, e Ae re s 5SQ(C. Egress_ Dual and Obst'n: General Bufldin'==Pasted (.,,.h,i,,,,5z `h `tS e�.f ids"'. -{ f� c, cP .2� _ Lacks aFrl3o®rs— �, C_f" C", ri I, ,, i.Lu ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONATION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES O P RJURY" > INSPECTOR A.M. DATE , �l —'S QZ TIME /D 3 P.M. A.M. THE NEXT SCHEDULED REINSPECTION ��` P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as PY rohibited b 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. T��f Q��$I2NSTABL.E LC?C/ 'TTQP6t 13iA SEWAGE`:# VILLA ' a to $ � A5ESSt}R`S.`:1iAF B.QT DW.,A.UXJZ S PdAME c$P OtdE I id SEPTIC TANK CAI'ACTfY LEAC�iII�1G:FACIL;'FY'.ttypr) ✓� 7'! (size) <_l PiO.t}FBF.I3�QOI�iS BtJS1aOR{?R OWrIER PERK FMATE GOIvIP'I ,AiCE DATA Separation Distance Between the Max�atumAdjustedGmandwater: etotheBottomofLsachtngFac�iftty Fie PnYate Water.Supply deli abdieach3ng Ftacdtty ( stay wis e�ust otu seta er:ant�ute feet of Ieacbteg facny) feet Edge pF Wetland end`I.eacbeng Faa'lty(If any wetlands exist wifhlsi 3tlt►h €leach�cig facil�cy) Furnished by �. . / : �� L�---�.,^ � � , �� :� P w e ,fin* ' =a, . . �� o r ,, _a .;� A�� -si6 � � 3' 6� ' ., .. �Y ` TOWN OF BARNSTABLE E�° Coke k, ATION �� Pt K t- SEWAGE # LAGE h i k / ASSESSOR'S MAP & LOT J--INSTALLER'S NAME&PHONE NO./N& K e 0 r G SEPTIC TANK CAPACITY f 5 0 0 LEACHING FACILITY: (type) 7 `Ik'Fc NO.OF BEDROOMS BUILDER OR OWNER /U\C C PERMTTDATE:. COMPLIANCE DATE: �(— 2. 7-0O 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 f� -11 S7 I �. to No. .�l/I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippIttation for Migpo!gar bp5tem Comgtruction Vermit Application for a Permit to Construct( )Repair( �ade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / /� �'s Name,Address and Tel.No. 'VV I Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 S—c�c� Type of S.A.S. t"—/ 4( 1,5-(O`1 Description of Soil Nature of Repairs o Alteratio (An wer 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 is ed b this and of alth. Signed Date ` Application Approved by Date Application Disapproved for the following reasons Permit No. r Date Issued boo - a Fee No. t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppYication for Mi0po5ar *p.5tem Con!5truction Permit Application for a Permit to Construct( )Repair( �de( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �l 's Name,Address and Tel.No. a Assessor's Map/Parcel I S� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 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 gallons per day. Calculated daily flow gallons.' Plan Date Number of sheets Revision Date Title Size of Septic Tank / O Type of S.A.S. t of Description of Soil J Nature of Repairs or Al ratio s(A wer when applicable) ( d� p ) A111v j �. t / 1/ 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 i d b this azd of alth. L(- �_ 00 ' Signed Date Application Approved by a Date ' Application Disapproved for the following reasons ( ,. Permit No. Date Issued ------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER , that the�n-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandon b �•L. 14 ( ne S ! accordance at 'has nstructed in with the provisions of Title 5 and the for Disposal System Construction Permit No. t Installer Designer " /) The iss �Jof ermit sh l ooi e e•nstrued as a guarantee that-the fle' i f•un i • as`desi e ItDate ✓�� C, �' Inspecto !1 r� f�} g ,$ No. ��-- — ------------------------ Fee ..-----^ -'.N. x THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Mizpooaf *pztem Con$truction 3permit i Y.•. Permission is hereby graqtedt on ;�ct( )Re r( )Up r den ( )System located at `p S 0 ,L and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to " r comply with Title 5 and the following local provisions or special conditions. Provided: Con c on us be co pleted within three years of the date of this p �"al 1 Date: Approved by \ Y' ': �., 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) ke- ea- in hereby certify that the application for disposal works construction permit signed by me dated 1r j —a 0 concerning the property located at VL 40— S� meets all of the following criteria: • The 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. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • 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 not be located less than five feet above the ma.,dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) V B) G.W. Elevation +the IMAY. High G.W. Adjustment . _ r DIFFERENCE BETWEEN A and B �. SIGNED : DATE: (Sketch proposed plan of system on back]. q:health folder.cent _ I TOWN OF BARNSTABLE -� �4 ' SEWAGE #� LOCATION VIIrLAGE �. _170�P 1'� f S ASSESSOR'S MAP & LOT S-3 -L INSTALLER'S NAME&PHONE NO. r�' SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 7 t vt t 4,1 l /S s z�eS NO.OF BEDROOMS i BUILDER OR OWNER PERMTTDA.TE: ��`� � �� COMPLIANCE DATE: �� j iSeparation 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 3C0.feet of leaching facility) Furnished by Cc I �c o......lq , i-v No ------ - -- >N'tea............._................ THE COMMONWEALTH OF MASSACHUSETTS 1 BOAR® OF HEALTH= Z _ ..........................................OF.....�3/ . ............................................... Appliratiun for Uiipusal Works. Toustrurfinn Frrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: .Location-Address or Lot No. ,�f. !i!L !/ a / P..�h! �l .T....----•-------•------------------------------- l Ow r Address a ................................... ....... sr...... Jl!57�, L >ln -_.......... I taller i Address Type of Building Size Lot.-A, ...Sq. feet Dwelling—No. of Bedrooms................ ....................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .................................. W Design Flow.......... ................gallons per person per day. Total daily flow...... -'�..�.®._...__..._..._...........gallons. W Septic Tank—Liquid'capacity/.- ��..gallons Length................ Width................ Diameter................ Depth................ F x Disposal Trench—No. .................... Width..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........Z......... Diameter..A?!- '..... Depth below inlet......�lo........... Total leaching area.Z FC7.....sq. ft. Z Other Distribution box Dosing tank ( ) _ Percolation Test Results Performed by?v -C/MC.,o t.V,6 ! MA I(.................. Date.AO/g,, Test Pit No. 1....?-........minutes per inch Depth of Test Pit....Z.:'......... Depth to ground water........................ Test Pit No. 2---.2.......minutes per inch Depth of Test Pit...e��........... Depth to ground water........................ a ----•-•------•-•--•--•-----•----•----••-••----------------------•••-•-•-------------------.......---......................................................... O Description of Soil--•• F" N r ��1'1.....S��AI/.7 .S�hLg F/11 ` //� .. C1✓n, —...ST3?�1k$.:........ c., .._ T ......... ----------------•••. --...--------------•--...-----------......-------•----••---...-------•---•---- VNature 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 ilTIL 5 of the State Sanitary Co The undersi further agrees not to place the system in operation until a Certificate of Compliance has be ss d by t e bo d health. �� 1 edZ I 420 - DateApplication Approved By-------- -- Lc ^ ............. ...... .. �''?`'7��........ Date Application Disapproved for the following reasons: -------------------------•-------•---------••--•---------------------...-----...------....... ....-•---•-•...................•--•-••---.....---•----------•----------•--.............------••----•---..._................------•---------------------------•---- -------------•-------------.......--- Date PermitNo........................................................ Issued----- .� --� .................... " Date 0 C-7 THE COMMONWEALTH OF MASSACHUSETTS BOARD- OF HEALTH rrs' .d.PL ...............OF......�'.,?",��A.1Y74 '......'° Appliraation for Dispmi al Works Tonstrnriiun rami# Application is hereby, made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ��.. ....... �l.:l �....� .E..... �e.f ., I........GyA Ri.6'I.P.L. 1 .VC........ ................ F+... �..... �Y.. �/iG' Location-Address or Lot No. 40 ' , 5 ....................................................... Own/, Add 11i� / j yin I to er Address Q Type of Building Size Lot. ...Sq. feet aDwelling—No. of Bedrooms.................. ....................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .........................•-•--•-------•--•-........•..--•--•------••-•-.......•-----••---•............--•----•----•--•--.....---•-•---...-•••..------ W Design Flow...........$q..110...............gallons per person per day. Total daily flow........ 50........_........ gall ons. W Septic Tank—Liquid capacity.. ,, 0.gallons Length................ Width................ Diameter................ Depth......... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......... ....... Diameter.__./a_5. ,.... Depth below inlet.......6......... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank '-' Percolation Test Results Performed by.. . ,&+ s +��i ! �Pe�•4! ................ Date... `'' f.�_.'.------.---. a Test Pit No..I..... ........minutes per inch Depth of Test Pit..... " ........ Depth to ground water------------------------- (i, Test Pit No. 2.....'2�, ......minutes per inch Depth of Test Pit----c! .......... Depth to ground water........................ 9 ........................................................................................................................................................... D Description of Soil...... AA .Sas -.. ?t! A!r s......--- U �?' •- - E� --•................................. U Nature of Repairs or Alterations—Answer when2pplicable._...fl ............................................................................... ..-------•-----------------------------•-•-..........•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iiT p 5 of the State Sanitary WCodeThe undersig further agrees not to place the system in operation'until a Certificate of Compliance has beeby the boa o6liealth. . s --rr - .. a ? x.F.. �� -gat- -✓�• APPlication Approved BY '. �� - '�` ....7 Date -Application Disapproved for the following reasons-------------------------------------•--•--.............•--•--•---•-•----------••--••---•• ...--•••••--•.---•- ------ ---------•---'---------------------------------------------------------------•-----•------- •------••------- Daate - } "Permit No......................................................... Issued-...................................................... Date i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ .\�Q._41.:1........OF........... ?..... .. . ... ..:................................ (9rdifiratr of ( ompliFatta THI T CE�'IFY, Th LtbIividual Sewage Disposal System constructed ( or Repaired ( ) by � . st tler at.... has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dateVK..-.4./..�_..7.Tj....................... THE ISSUANCE OF-THIS CERTIFICATE SHALL NOT BE CON UE® AS A GUARANTEE THAT THE SYSTEM )WLL FUNCTION SATISFACTORY. DATE7........--- ..."�..�.7--------------------------------------- Inspector...... -... -------- -- ....... F!r THE COMMONWEALTH OF MASSACHUSETTS ((^^ BOARD F HEA),.T. r. No........................ FPU:................... . -- Permiss� is hereby gran ed...... -- ......... --. ....... to C�t, � � or epa' ` ( � ) an Individ �w,age 7ze_ySz(t iS 9�l atNo"`. ............................................. ......�/ Street as shown on the application for Disposal Works Construction rmit 1 Date ._- .x--• ................ oard of H��[�h ..............•--•--...r -- ....... DATE......7..................•7 -....................................... _ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS NAME ADDRESS 3 ��"�e- VILLAGE lZ LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL (Give same information for any additional tanks on reverse side of card) DATE OF PURCHASE OF EACH: 1. 2. 3. 4. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED __. DID NOT PASS A P P R O V E D - Barnstaole Conservation Commission' Signed WDa SULLIVAN, AR HUR 134 Pine St. ,West Barnstak�l. i !i << cr r 1 1 l{� e m R�� N C N PJ2, - I W N N N ��• f' } A i 2 D � 7 I Famly �t zn- 1. I ,9S j \ 7 6 N w i r ST 6__ 9 0 I Fnmlj ^ LY t(l1ItTsz MY Wz 'r a. g •a 9 t I. I i I I I f. z i I ;, /! `f p.9 C V ,\✓ ,. . --„-- a __:.�, _o__. �.a p��,�� c��-�v r-r� f r'o�� i e_ `` S .. � , .' - /G f✓ �- �' :'- ,$ G A� �` f ! C,Q ,_;� SGHe 13. 40 P. V. C- OAe ( rn,i i�mc/r�? %4 -per' Fooff- f Hof 7 / Ec�u.yL TG 5 :^�c �' '+►" a;t~ /B - %2' waS�r�sd' Stone I ftv7 _ - � � F t . . y 'C7�f Q "�C T 4CPf5T. 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