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HomeMy WebLinkAbout0184 WOODSIDE ROAD - Health 184 Woodside ; West Barnstable \ A= 127 - 008 0 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 184 Woodside Drive Property Address Robert Pritchard Owner Owner's Name information is required for every West Barnstable MA 02668 80/08/1`17 page. City/Town state Zip Code: Date of Inspection Inspection results must be submitted on.this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information fining out forms ( n on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections rffi Company Name P.O.Box 896 Company Address East Dennis MA 02641. City/Town state .Zip.Code � 508-385-7608 SI 3742 _' a Telephone Number license Number3} ~3 C�p B. Certification ' I certify that I have personally inspected the sewage disposal system at this address and that the- --A information reported below is true, accurate and complete as of the time of the inspection.The inspect was performed based on my training and experience in the proper function and maintenance oQ1 sits; sewage disposal systems. l 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 Evaluation by the Local Approving Authority 08/1.4/11 Inspector's signature . Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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. I . I t5ins•11/1 D Title 6 Official Inspection Form:Subs4Seeposal ern•Page 1 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert.Pritchard Owner Owner's Flame information is West Barnstable MA 02668 80/08/11 required for every page. C Rawn state. Zip Code Date of Inspection. �?' B. Certification (cunt.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D. A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15:303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 over20 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. I *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. I ❑ Y ❑; N ❑ ND(Explain below): t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert Pritchard Owner Owner's Name information is West Barnstable MA 02668 80108l11 required for every page. Cityr town state Zip Code Date of Inspection B. Certification (cunt.) B)14 System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND,(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑: Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System.will pass unless Board:of Health.determines in accordance with 310 CMR 15.303(1)(b)that the system,is not functioning in a manner which will'protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of asurface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt.marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert Pritchard Owner Owner's Flame information is West Barnstable MA 02668 80/08/11 required for every 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 than /day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Officialinspection Form. s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert:Pritchard Owner Owner's Name information is required for every West'Barnstable MA 02668 80/08/11 page. Cityrrown state Zip Code Date of Inspection B. Certification (coot.) Yes No El ® 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. ❑ 0 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 emast 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 El ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area:—IWPA)or a mapped Zone 11 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 MR 15.304.The system owner should contact the.appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 184 Woodside.Drive Property Address Robert Pritchard Owner Owner's Name information is West Barnstable MA 02668 80/08/11 required for every paje. aWrown State Zip Code Date of Inspectfon C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was;the facility or dwelling;inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of(break out? ® ❑ Were all system components,excluding,the SAS,located.on site?' ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? Cl 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)1 D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): 330 t5ins•I Ill Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert Pritchard Owner Owner's Name information is required for every West Barnstable MA 02668 80/08/11 page Cityrrown State Zip Code Date of Inspection D. System Information Description: 2. Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[f yes separate inspection required] 0! Yes ❑ No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: bate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/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: Tie 5=1o11"Oeefic,c0�^^:.SL'suace W." a 0-.Po.al%.—..o.,..e 7 el 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 184 Woodside Drive Property address Robert.Pritchard Owner Owner's Name information is required for every West Barnstable MA 02668 80/08/11 page. Citylrown State Zip Code Date of Inspection D. System. Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box,;soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(f yes,attach previous inspection records,if any) Innovative/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DE approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form "s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 184 Woodside;Drive Property Address Robert.Pritchard Owner Owner's Name information is West Barnstable MA 02668 80/08/11 required for every page. City/Town lstate. Zip Code Date of Inspection. D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 03/03/89 per BOH Were sewage odors detected when arriving at the site? 0 Yes 0 No Building Sewer(locate on site plan): Depth below grade: 1.5 P g feet Material of construction: ❑cast iron [0 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): 0.6 Depth below grade: feet: Material of construction: ®concrete ❑ metal fiberglass polyethylene ❑other(explain) If tank is metal,list age: years. Is age confirmed,by a Certificate of Compliance?(attach a copy of certificate) 01 Yes 0 No Dimensions: 1000 gal 5" Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert Pritchard Owner Owner's Name information is West Barnstable MA 02668 80/08/11 required for every page Citylrown State Zip Code Date of inspection, D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert. 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, Sins=11:10 Tice 5 O filial Inspection Ferm SubsuKace Se vage 1-tsposat!-&M Page'C a 17 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert.Pritchard Owner Owner's Name information is West Bamstable MA 02668 80/08/11 required for every page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) 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.? ❑. YeST No t5ins-11110 Tige 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert Pritchard Owner Owner's Name information is required for every West Barnstable MA 02668 80/08/11 page Cityfrown 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 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.): No box present Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and.appurtenances,etc.): Soil Absorption System(SAS) (locate on site plan,excavation not required): If SAS not located,explain why: t5ins-11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 12 of 1; Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert.Pritchard. Owner Owner's flame information is West Barnstable MA 02668 80/08/11 required for every page. Citylrown state Zip Code Date of Inspection. D. System Information (coot.) Type: ® Teaching:pits number:. 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has a 6'x6'precast pit surrounded by a foot of stone.There was3.9 feet of liquid with no staining above. 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 f5ins•11110 Title 5 Official inspection Form:Subsurface Sewage Oisposai System.-rage 13 of 17 Commonwealth of:Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 184 Woodside Drive Property Address Robert.Pritchard Owner Owner's Name information is required for every West Barnstable MA 02668 80/08/11 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts T Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert Pritchard Owner Owner's Name information is required for every West Barnstable MA 02668 80/08/11 page. City/Town State Zip Code Date of inspection D. System Information (cunt.) 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 as Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert Pritchard Owner Owners flame information is West Barnstable MA 02668 80/08/11 required for every page_ C4 rown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells f Estimated depth to high ground water. feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system-design plans on record If checked,,date of design plan reviewed: Date ❑ Observed site (abutting.property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: El Checked with local excavators installers- attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet I Before filing this Inspection Report,,please see Report.Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 184 Woodside Drive Property Address Robert Pritchard Owner Owner's Name requiratifore West Barnstable MA 02668 80/08/11'' required for every page. Ckyrrown 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•11/10 ride 5 Official Inspection Form:Subsurface Sewage.Disposaf System•Page 17 of 17 TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date ^y f �0 ` o Time: In Out Owner Y`'G'v Tenant Address Address 8 � Compliance Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities ,Ca 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 0-0 ll 16. Sewage Disposal $ — ( vV 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed 3 tL e. (aU Y PART II 37. Placarding of Condemned Dwelling; _ Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here I 05 TO •00 J r Sat C it 1-16 � S 1 LL FoAm30 C TM THE COMMONWEALTH OF MASSACHUSETTS &w Hosas 8 WARREN BOARD OF HEALTH CITY/TOWN ` w �A, l.. a DEPARTMENT 2Oo Ntal�l �'C. US 7_�6ej j GSM Svb y`0� ( 1 TELEPHONE (,�,It4l �j,eRNS1�b�L Address 1 dC OSl f7L _ Occupant_. f4(,A.._Nil Floor Apartment No. No. of Occupants N/A_ s No.of Habitable Rooms No.Sleeping Rooms (41 No.dwelling or rooming units No.Stories.p— Name and address of owner � C �- "� CNA� �JD V G 13 2 0 7 (M,�► Remarks Reg. Vio. YARD Out bldqs.: 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: G� ID ar✓VI Dampness: V.J A VAttaT Stairs: ea,a G S 5,x dr+K Lighting: t do STRUCTURE INT. Hall,Stairway: or•M 0 st'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: LZ 9410 le— Hall Windows: zo" HEATING himne s: 2. Central ❑ ❑ N E ui . Repair TYPE: Stacks, Flues,Vents.- PLUMBING: Supply Line: ❑ MS ❑ ST Waste Line: H.W.Tanks Safety and Vents ELECTRIC Panels, Meters,Cir.: C ❑ 110 EV220 Fusin ,Grnd.: 'tr o S'� i C..M�ti AMP: Gen.Cond. Distrib. Box: o1 cv.I 4A r+4 Gav1Gve— Gen. Basement Wiring: D C[ten.Jjpope LAotjq.%t`P44IGL DWELLING UNIT entil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den V_ Living Room Bedroom 1 1 2 Bedroom 2 Bedroom 3 ZU Bedroom 4 yUsAAA-WAJ.-I Hot Water Facil. Sup.Ten.,Gas,-�ect.: Stacks, F Vents, of 'es: Kitchen Facilities Sink ove 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 b it to fz Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH Q _ � G„ MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE /�/ OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF P RJURY." INSPECTOR TITLE A.M. DATE 2 TIME u : t30 P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair-Health or Safety The following conditions, when found to.exist.in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of,a person or persons occupying the premises.This listing is composed of those items which are deemed to-always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other.violation has the potential to fall within this category in any given.specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found,to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply'of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150'(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (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 arid 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. AsBuilt Page 1 of 1 �Ll TOWN OF BARNSTABLE LOCATION SEWAGE # 0071 O U VILLAGE —�Jcr-�w,� _ ASSESSOR'S MAP G LOT I2') 00 INSTALLER'S NAME & PHONE NO. Q�,g SEPTIC TANK CAPACITY 1poo LEACHING FACILITYjtype) / (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: — a , DATE COIIPLIANCE ISSUED; VARIANCE GRANTED: Yes No i hovse 41 Oe /000� �u http://issgl2/intranet/propdata/prebuilt.aspx?mappar=127008&seq=1 3/6/2012 TOWN'OF BARNSTABLE 'LOCATION O SEWAGE # /0 o� j VILLAGE 2_&Jd-A-v,�,_ ASSESSOR'S ,MAP & LOT �� o INSTALLER'S NAME & PHONE NO. G 1 SEPTIC TANK CAPACITY `poa g,�Q LEACHING FACILITY:(type) , (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: — DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �" 1 oos 2 sloe, /000 (/1 No............ Fmic.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF................--..........._.......... Allpfiration for Dhipasal Morkii Tomitrurtion "amit Application is hereby made for a Permit to Construct or Repair V� an Individual Sewage Disposal System at: �.. �. ..V.-..Ido.... ......... - -. b.....•••-•-..........•••....................•-.•-•-- lion- dress or Lot No. .......................................... .................................................................................................. O)vner Add, ... . .... .... . ... .. ......9.......... ...... .......4�h .................. Installer Address U T e of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--_---.3..................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank—Liquid capacity...........gallons Length................ Width........_._.__.. Diameter-_.______-___-__ Depth...._..._...._.. Disposal Trench—No..................... Width.................... Total Length..__..............__ Total leaching area....................sq. f t. Seepage Pit No_____________________ Diameter.........___.__..... Depth below inlet.............._..... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date--------------------------------------- Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water-___-.--___._-_--__-__-. (i Test Pit No. 2................niiwtes per inch Depth of Test Pit Deppt ound wate_r...................... 9 ........ . .........V........ ...Am- ....... 0 Description of Soil--------.P1. ................. -----------%--------------------------------------------------------------- UW .......................................................................... .... 104 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'4"1.TI 1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by tear of health, Signed--. . .. ... .... ..... ................. -- - --------------------- -------------------------- Application Approved By.............. .... . ........ . . . . ......... ... ..... ............ .. ..r.............................. ....;. .................... Date .......................... Application Disapproved for the following reasons:............. ............................................................ .......... ...............................................................................................................................................................:........................................ 04�7 Date e17 V4_4 Permit No--------0...I........................................ Issued.- . ----------- Date _, .-.:.. No.. ..�' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. .............----------_OF.................................................................................... Allp irFation for Disposal Murks Toustrurtion Prrmit Application is hereby trade for a Permit to Construct_ ( ) or Repair ( ✓) an Individual Sewage Disposal System at: ' ........ ._.L .1.�1 . ........ �� .. f` /') fJ Location address or Lot No. .......!............._.............................t............................................ ............•..................................................................................... ownir d // Address (/ I sta er Address d T � of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms---_�...................................Expansion Attic ( ) Garbage Grinder ( ) p� Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) A 1 Other fixtures ---------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—'_`To. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-_______-___-__---_ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-___---___-__-_.-__-___. I (i Test Pit No. 2................minute er inch l Depth of Test Pit.................... Depth to ,round water__.:-_____.____........ DDescription of Soil............ ='=f -............................................. -====-------------------------------------------------------------------------- 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;. a p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of ComplianceWhasbeissued by th b aryl'of health. SigCE '.•-- •...,...:,. ` `-'r�_ -------------------------------- Date ry Application Approved By.......•--•--• ..... -----------•-------•---------•--- 'm-�/" -----•• - Date Application Disapproved for the following reasons:--..........7 ...........••--•-•-•----------------------------•----•.-----•.-•_--•.-•--------••.....-------•-•-•------......-•-•--••--••-----••....----•••-•-•--.•..•..-•-•---••.--.-----...-------•--•••.-••--.----.._ Date Permit No.------ .......r............................. Issued.. "' -"?�--/--....-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................I..............OF............................................................................­....... (IrrtifirFatt of TuMplitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ' by--------------_-----w- 1 r.......k-ae... - Installer at. ---------------•-----•-----------•-••. -------------------------------------------------------------------------•-----•-••---•-•--•-- has been installed in accordance with the provisions of TITIE �5 of The State Sanitary Code as described in the ---..... dated..... application for Disposal Works Construction Permit No-------✓ ✓._- ; - -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH may' �� ..........:...0F...p !GL� CY -----••. NO... � FEE.. ...' . Disposal Works T-alustudion Prrutit Permission is hereby granted =----------------•------....-•-•-------.....................---...... to Construct ( ) or Repair ( an Individual Sewage Disposal Sy4em atNo.. ,�1� 1 a`" �..c °�! -----i # .......................................... street r as shown on the application for Disposal Works Construction Permit�No#.1?dF'/ Dated_. f r._ .... p° t Board of Health DATE. !� l.- P, '/ .--:.----.--•-•------------- ' FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS I� 7-1 No..........22 ...............I..:. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF........... iGE3Z� .:,....1 _..._......_. Apphration -for Dispotial Workii Towitrurtion Vrfmil Application is hereby'made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 0 e................... ................................. /jr-le - ............................................. -11 Ad: Ole or Lot No. ......................................... .... . ....... OC.............. 0 ............ ....................................................... ner Address ................................. A . ........ ..... ------------------------------------.......*-----------------------------------------------------Installer --------- ...............*..... Address • U Type of Building Size Lot_*---4*.#--Sq. feet Dwelling—No. of Bedrooms-----------03---_--------------------Expansion Attic Garbage Grinder A4 Other—Type of Building ............................ No. of persons-_--__-____--__-__-____-_.-- Showers ( ) — Cafeteria 04 Other fixtures ---------------------------- ------------------------------------------------------------------------------------------------------------------------- Design Flow.............................................gMons per pet-son per day. Total daily flow............................................gallons. Pi Septic Tank—Liquid capacityl-S"- flons Length................. Width--__---_-__-- Diameter---------------- Depth._-.---_-.----- Disposal Trench—No- -------------------- Width..... Total Length--_-_____--_______-- Total leaching area--------------------sq. ft.. Depth below i I Seepage Pit No.......k--------- Diameter n e ----------- Total leaching area------------------sq. A------------ Other Distribution box Dosing tank Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit.....__.___.__._.._. Depth to ground water...--_-__.-.--_.-.-.-.-. 4q Test Pit No. 2_--------------minutes per inch Depth of Test Pit.--_-__-____________ Depth to ground water.-_--_-_-____-_----. 0 D ........ ­w-- � ---- --a- ------ -- . .-. Description iW .. ...... ......... ... . ...... . ------ --- -.--.-.--.-.--------------------------------------------------------------------------------------------------------------------------------- - ----- -­------------ ........... U .... .../A W Z ---------------------------------------------------------------------------------------------------------------------------------------------------------------I--------------------------------------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be& its d by the board health. A Signed Date Application Approved By------ . ..... . ......... ....... ... ............... --- ------------ T Date Application Disapproved for the following reasons:........................................... -------------------------------------------------------------------- ....................................................................... ------------------------------------------------------------------------------------------------------ Date Permit No................................................... Issued......If ------------------------.......................... Date No........ .- ? 3�z�s 1......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r 1 . ................................. Appliration for M-nVosal Works TottMrurtiou Vamit sir Application is hereby'made for a Permit to Construct:(' ) or Repair ( ) an Individual Sewaget{Disposal h System at s ,r ' - L.O.0 Address or Lot No. .. o- s fie` ner Address wti i , Installer Address M., .Type of Building � Size Lot..: :�rA.Sq. feet U F...I Dwelling—No. of Bedrooms - _ _ .____.__.Expansion Attic (` ) Garbage Grinder .( .8 a .'� Other—Type of Building ............................ No. of persons_-_____----_______-_____.__ Showers ( ) — Cafeteria ( ) Q Other fixtures .. = --------------------- --•------------------------..------ W Design Flow............................. Mons per pet son "per day. Total daily flow-_-_-_____--__----_-___-_-_..____-.-----....gallons �R; Se:tic "1:,n1:—Liquid cauacrtv tllons Length____ Width.......... .... Diameter-............... Depth.. _ ':'` Disgosal.Trench, No -_ ____--: Wtdth_-_ _:_-:_-_ - Total Length.................... Total leaching area...............-----sq. ft. Seepage Pit No--------------------- Diameter....................... Dept below inl et...__y�, .___.__. Total 1 ac iing area..---._..__...._.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �/ " /" Percolation Test Results Performed bY..... ......... ••---• . --•--- Date--------------------------------------- Test Pit N.o.;l;�______________minutes per inch Depth,of..Test Pit-------------------- Depth to ground water..--_-_-._....-_-_---. (4 Test F t:nNo. 2°'_"._......_..minutes per inch Depth of Test Pit---------------------- Depth to ground water--.--._--__-___.____ O -� V dDescription of Soil 14 ................. ........../ '. �t�. ---- 14 ----••---------- - ---------------------•-----------------------•--------------------- ---------------------------------------------------------------------- U Nature of Repairs or Alterations Answer when applicable...............:......................................•-_--._._-.__......._....-.__.--_----- - Agreement The undersigned 'agrees to install -the aforedescribed Individual Sewage3Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate.of Compliance has-be is u d by the board;d health ,, Fn Signe � ----------------- Date Application Approved By......... - Date Application Disapproved for the following reasons:............. :................................................................................................ ._.........-•----•--------------•------•---------------------•••••..•_.... ------------------------------- Date Permit No. Issued. =` - --------------- Date THE COMMONWEALTH OF MASSACHUSETTS , 1 "- BOAR OF HEALTH ..........OF.......... :.:.:.. . ..::.' "Tirdifircate, of Tontpliatta T IS. CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by - ,C�/ stallac y// .�3r` AA 40 has been installed in accordance with the provisions.of Article"XI of The State Sanitary Code as described in t)e 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.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tit'.. O F.... .... -- ... ................................ No. _._...... � E••.•... FE l ..................... r Permi• .... ssion is hereby granted------ -•---............ ..... ...........•-•--------------...._..- :........ •------- -•--- to Cons I + or Re air ( ) anindivl Sewa ie al System j /{ '� Street gas shown on the application for Disposal Works Construction Permit : _ ated_____. ' T- ': 7........... �- 77 Board of Health DATE•-.-LP � ✓r FORM 125.5 HOBBS & WARREN. .INC.. PUBLISHERS - ' _ Y 02 MACri J 24 4 � • SE1�t'i G {4u1L ca (r is ` Fau�Q,, tl' LOT i1 JN OF M WILLIA`IC. NYE ,p No. 19334 O L�Q 1F1E1� PLOT P1_.�cS,�i ^'ST °� tOCATIo ��iL.ST- ��j21.1��AR SGAL �' d-O -t3AT l �,(n ."'I { r-rRTtI=l( T"AT TNE: C"-vwf�pA��►.� SUayv�.l PLA 1 R FAQ ►.1 Wr--Z E o" CQMPLY'G W t TN TWG: 51 U'E.LI► C-- Aura SETI',ACV- QEQc�1tZEN�E ITS OF "r"C ti ZOww of DATE �___ W • G �.1 BQY.TCiZ � WYF-- 1u.tC_ REG1ScF-=.s�D LAttp SUf�vcYoczS T"ts VLAN Is UOT aASex�l 064 AN OSTEiZV1l,.t.E o nxass. 114,9 EJAAEWT 4 THE OF�S�f S S�aawt� APPI_tLA�1T 1�� GNAL l,.bT 13E USEc7 To oeTC.ZMiN& 1C>T' Lt14 S i "1` r Pj Zd' • SfPftc �4� �/ i f� Ftsvkiq tr LOT It 1,;t - -�tN OF r �•i• WiLLIPA 9G�` Y cy cEeT Fv p two,- ..,dr� �No. 39334 O LOCATIO" WEE s`T' �4�1�5Tt�f3Lt R CM9TIFV THAT Ti4r-- r-oL)wDPMf) Z SWAwj f PLA►�a R��'�RE�.iGE 9Se G t4J CoAAPL%eS W i TIA TtAG: 51 U*-U NE A►IP, SETeACIC AEQut¢ENtEWTS .oF THE �-�'oWU ,off G A��sT�•t��.� , �...t�►J 30�� Z3et P�Gc.:.. 13 DAT1= G 8�4XTC�Z IJsjE ',1wG_ .' . REGiSi*.�ZEt� LA1Jp SV>`VtYC�r�S TI41'S DtAN IS LAOt SAsev W UMEWT QVG�{. THE oF�-'SEirS SNrwla APPL_I GA1JT. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: ��.`� UJ voc S`� ..... mod....,...... ..............................,c - ........................... ..... Location 1. ........,.................... ProposedUse -�...................( C..I...... ..................................................................... . ......................... Fire District c-tJ.::...�:!c ....................... Zoning District ........ .... ..�............................................. LI Name of Owner ... n �!!k 0,(� :.:� :.Address ........ .. ...................�. ..................... •• " Name of Builder Address ........... ............••••• . . r.....:....... Name of Architect ..................... ..............................................Address .................................................................................... ... C\�� c_ Number of Rooms ............................................... ..................Foundation ...................:.....0....`N......... ................. ,s r .......�. ..... ..... ..Roofing ' ���boo� .. ....................... Exterior �................. h co.. Floors \N ..... ........... �� .......................Interior .... ... .t..1. ...........................Plumbing .......... .19-:: •............................................................. l ! .............Approximate Cost ........ ..�Q ................................. Fireplace ..... �.... .. . Definitive Plan Approved by Planning Board ---------------_---------------19-------- Area ........ ..�..l.�..... ............ Diagram of Lot and Building with Dimensions Fee ........�� ..�................. SUBJECT TO APPROVAL OF BOARD OF HEALTH �Ijrn 1k' - / k 72� 161K 30 - ! � 2� 3 . 171 ? s Ace I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name - ..••..