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Home My WebLink About1415 HYANNIS-BARNSTABLE ROAD - Health z � 1415 KyANNIS D, 13ARNS7A�3LE s : A- 2 97-010 . .J : e 1, qp i Commonwealth of Massachusetts Title 5 Official Inspection' Form p , Subsurface Sewage.Disposal System Form • Not for Voluntary Assessments J .1 ter Property Address �o seat dole✓, Owner Owner's Name t p l information is �Q r h f�9 �t t9d - .—required for every page. Cityrrown State Zip Code Date of/rispedlion.` Inspection results must.be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the'end of the form., Important, ; When filling out A. General Information forms on the computer,use 1.• Ins ector: only the tab key P to move your ��/� cursor-do not use the return Name of Inspector . C key. EA 11 D Company Nam Company Address w �/atw, 001b4(.4 Cityrrown r� f/ r0 / �_.7— / T-SL StateO Q Zip Code TelephonMumbeV Li O cense Number B. Certification I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training'and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system.: ❑ Passes, Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority m Inspe or's Signature /O 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.sentto the system owner and copies senfto the'buy&, 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 y perform in the future the same or different conditions of use. under 15ins•09108 Titre 5 Offidal Inspection Form:SuDsurfacesewage posal System•Page 1 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. Property Address Owner Owner's Name information is 4rr� 0. 2C J.2 floZ required for every page. City/Town State Zip Code Date of tifispectign B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) Syste onditionally 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. Ifs"not determined,".please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I L S� CIA— t5ins•09/o8 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System'•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments it Property Address Owner Owner's Name J_ J information is a�Ns 7'� ,L / /y d v y k p /� ho required forJ 1�� D every page. City/Town State Zip Code Date f inspiction B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is'not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•ogfoe Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 17 �i Commonwealth of Massachusetts Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments gNNrS 9a.,MXJ-4ik Property Address C2,t)2 . Owner Owner's Name, ,y information is /��1�L required for every page. City/Town State Zip Code Date&lnsp4cfion 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: r '•This system passes if.the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ Q� 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 ❑ L� 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 '/2 day flow 15,ns•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary/Assessments Property Address eq � pr Owner Owner's Name information is 4 AW required for �J every page. City/Town State Zip Code Date of I pecti 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. Q� 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. ❑ L�' 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.] ❑ T system is a cesspool serving a facility with a design flow of 2000gpd- 0,000gpd. ❑ 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 p, If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office'of the Department. t5ins•09108 ` Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 5 of 17 I ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / UV Property Address / e a C/ ¢✓' Owner Owner's Name information is 4 rn sT� required for zp every page. City/Town State Zip Code Date 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 ❑ Lf re any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? fJ' t_J Was the site inspected,for signs of break out? L� Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has een determined based on: ❑ Existing information. For example, a plan at the Board of Health. O 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 n(desi : / N 9 ) umber of bedrooms (actual); DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): V r isins•og/o8 Title 5 Official Inspection Form:Subsurface:Sewage Disposal System-Page 6 of 17 i e , A— Commonwealth of Massachusetts / Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not fore�Voluntary Assessments, a N N,� iESs.r.s�,11� /I?ct Property Address Q.a -Qit/ Owner Owner's Name / information is required for ✓I'1STu�/�— � //! every page. Citylrown State Zip Code Date of Inipectiorf D. System Information Description: 1 • Sir 7r.► ?,O h /Jo / /e-tc- c;2xtt�'-_;kdo Number of current residents: Does residence have a garbage grinder? ❑ Yes a No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ^ Laundry system inspected? ❑ Yes 19�0 Seasonal use? 911es ❑- No Water meter readings, if available (Int 2 years usage (gpd)): Detail:, Sump pump? ❑ Yes o Last date of occupancy: 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: i5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 l Commonwealth of Massachusetts Title 5 Official,, Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments Property Address p Owner Owner's Nameinformati 1 l required forts rho -T�+ �lC. / �oc _F oZ Ito - every page. City/Town State Zip Code, Date of I specti n D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General.Information Pumping Records: Source of information: ry Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: TYPe Septic tank, distribution box, soil absorption system ❑ Single cesspool . ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the D;EP approval. ❑ Other (describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official 'inspection Fora Subsurface Sewage Disposal System Form• Not forVoluntary /Assessments / . Property Address ti I� Owner Owner's Name 1 AA, l information is �hs7 g / / O�630� 4?)required for every page. City/Town State Zip,,Code Date-AT- D. System Information (cons.) 1 Approximate age of all c ponents date installed (if known) and source of information: 19s - /Soo — wo Were sewage odors detected when arriving at the site? ❑ Yes o Building Sewer(locate on site plan): Depth below grade: feet Material nstruction: cast iron PVC ❑ other (explain): 1< 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): l� Depth below grade: feet Material onstruction: oncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) �q017 If tank is metal, list age: years Is age confirmed by ar Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: - t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments IS Property Address r / Owner Owners Name information is 1''1 6�oZ /n,� required for rN every page. CitylTown State Zip Code Date of D. System Information (cont.) Septic Tank (cont.) JD Distance from top of sludge to bottom of outlet tee or baffle Scum thickness �1 Distance from top of scum to top of outlet tee or baffle r- Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? RQ �Q�, ce Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ^--_ / / dot Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: -- --_- " --------____-- Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i- _ Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is 6 1� ad �� ' A*. required for ✓Hs/� � //?�� every 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: l 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.): t I . 'Attach copy of current pumping contract (requiretl). Is copy attached? ❑ Yes ❑ No t&ns•09/08 Title 5 Official Inspection-Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessments Property Address ell Owner Owner's Name information is G�✓1s TG bl� �� ,� required for every page. City/Town State Zip Code Date of Ospectop 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.): a .Sa/ CI 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: r - Title 5 Offic,al Inspection Form:Subsurface Sewage Disposal System.Page 12 of 17 Commonwealth of Massachusetts fD Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments IS Gr1 rl /1 /✓Cr✓ISTy�� Property Address Q / CJ -or Owner Owner's Name ,}/) information is required for every page. Cityfrown State Zip Code Date a Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers ` number: ❑ aching 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.): C. !Pa h 4�;i 1^ a 7� A e. A f, 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•09108 Tine 5 official inspection Form:subsurface sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ll ei,7 jr -Z Property Address �g �QV Owner Owner's Name information is J ll required for every page. City/Town State Zip,Code Date of lKspectiorf 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.): l 'Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i r Commonwealth of Massachusetts Tine 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Is �N►�/f /�/N S�a 7 Property Address Owner Owner's Name information is / required for 4iMSbl� � �oZ 7D every page. CityfTown State Zip Code Date 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 p c water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately f _a • Fe n ce- f- aly 0-7 "" � • —`tea� — { Corer . le to f i5ins•09/08 Title 5 OKdal insp ection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusett'.s MEMO Title 5 Official- Inspection Form Subsurface,Sewage Disposal System Form • Not for Voluntary Assessments t S 4nvt�r' 4J,I/.. Property Address J / Owner Owner P-, C'd..t✓ s Name/- information is ` required for grrf.t az63c�-- every page. Utyrrown t State Zip Code Date Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ..'/V0 E A21 . Estimated depth to high ground water: fe et Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: i You must describe how you established the high ground water elevation: o4hCv� 1(9C-V44e_� t A k vt c w.. V-e � tom, Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•Moe Tgle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 l ` I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form • Not for Voluntary Assessments Property Address Owner Owner's Name information is $ 02 JD required for Gl✓l f 7 aAlulzevery page. CirylTown State Zip Code Date of IrApection E.t;Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed LT Sy m Information - Estimated depth to high groundwater, Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i 1 - 4 Ih' 15ins•09/08 Tide 5 omclal Inspection forth:Subsurface Sewage Disposal System,Page 17 of 17 , I , !)o No. Fee Ar/ ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for �hgpo!gdr &p5tem CCon5tructiott permit Application for a Permit to Construct( ) Repair(!/Upgrade( ) Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. f Owner's Name,Address,and Tel.� N /'�/� A k� 6,4"SIA !te a. X� ®PiA Assessor's Map/Parcel �A15r, Installer's Name,Address,and Tel.No. _/ 03 Ir 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(min,required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �',�l� Type of S.A.S. Description of Soil Nature of Repairs rAltera�ons(Answ5rwlyen applicable) 1�G�b� �, .��i �/�alb 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 Environm a ode and not to place the stem in operation until a Certificate of Compliance has been issued by thi Bo d of Health. Date Sig Application Approved by Date Application Disapproved y: Date `for-the following reasons Permit No. Date Issued �7 No. . ! / / Fee v" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes `�~•.� Rpplication for Mi!6pomtl *pgtern Cori!5truction Verrnit Application for a Permit.to Construct O Repair(4pgrAe O Abandon O ❑ Complete System ❑Individual Components "^h vrr 11v,/mil Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel w �� <°�-£ •fit..✓ ��' �� Installer's Name,Address,and Tel.No. /� '?�j�'�/yj Designer's Name,Address and Tel.No. Type of Building: {- - .C/p Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder Other _Type:of Building No.of Persons Showers( ) Cafeteria( ) Other-Fixtures :a Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic:Tank ^ Type of S.A.S. Description of Soil ? Nature of Repairs or Alterations(Answer when applicable) T R 11u w ;. J Date last inspected: Agreement: d�es The undersigned agrees to ensure the constructi3n and maintenance of the afore described on-site sewage disposal system-in accordance with the provisions of Title 5 of the Environmenr'Code and not to place the system in operation until a�Certif Cate of Compliance has been issued by this Board of Health ' Si ed �. Date f/( / Application Approved b ylf` 7//i�f f'� J Date Application Disapproved by: ~X-7 Date ry for the following reasons r" Permit No. '� Date Issued — — " --,THF4 COMMONWEALTH OF MASSACHUSETTS BARNSTABLEMAS"SACHUSETT 0. t If k,lic qr S ?(1,c 14 kA 0oI Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed ( ) Repaired ( , ') ' Upgraded ( ) Abandoned( )by f at I y (S 1`�yti f,/n j:s 139 (n S�.�t 0) ( �� `�35.1 S)-y 1�;Nas-been oon's)tructteed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. C/�`�, dated t Installer (`��.� Designer #bedrooms Approved design flo _ gpd The issuance of this permit shall-not be construed as a g afrantee that the system wilhfi]ttctio�n as desi " ed. 'Q r - Date l I �u Inspector �/ -P I` J } ———— -- v ------=— Fee --------------= No. /✓J J/y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS , Migogal i§p!6tem Con!6truction Vermit . Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon System located at 1)A el and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5.and the following local provisions or special conditions. t �j Provided: Constru tion/ N/,/ust b comp within three years of the date of thiserm t.v 'Date t� Approved by � • . FORM3O &W HOBBSSWARRENTI THE COMMONWEALTH.OFMASSACHUSETTS BOARD OF HEALTH So aw,s-cA�� CITYITOWN DEPARTMENT ADDRESS <0 ro f�.zz - 4l L yy } TELEPHONE Address i.y D ',o.QN-VASICccupant V+A"Ck of 1iZ. 0 MICA AV 0 Floor - "- Apar1-ment No. No. of Occupants No. of Habitable Rooms No.Sleeping Rooms-1 No.dwelling or rooming units No.Stories Name and address of owner 1D bOL&T 11 ACQ¢A, 2,5- � `t uo OLD am lee w 0 -] Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish FEZ Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows.- Roof - Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE 1 Hall,Stairway: Obst'n.:- Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING himne s: Central Y ElN E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Su I Line: Elms ❑ S ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.C nd. Distrib. Box: G Basement Wiring DWELLING UNIT PO entil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 /0 2 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, bil, Elect.: Stac s, s, feties: Kitchen Facilities ink o k.Ztove Bathing,Toilet Facil. Ven ., um .,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted 770 6 Q dS U4 Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPEC ION REP IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES PERJU INSPECTO TITLE A.M. DATE 7 TIME ' P.M. A.M. THE NEXT SCHEDULED REINSPECTION + y P.M. `�_�; may,.•-,;+�.. .,�.��... ,• to ... ..., ..:.., ... ... ......�.. �.. .:,.. ..�,�.a,,:;k;., ..7; .:.nd7"],�v'!+!F.'� r�...�y'xis.^�fr "�; i?"�K ',w•.w,. ti� rv.4..., ... ..,..., ,.r. r'.. : 7 410.750: Conditions Deemed to Endanger or Impair'Health or Safety The following conditions,when,foLind 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 andtherefore is not included in this listing.-Failure to include shall in no be construed as'a determination that other violations or conditions may not be found to fall within this category. Nor shall fa41Ure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 40.830 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 440.180 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 410.800. (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. r (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 1.05 CMR 410.600, 410.601 or 41.0.602 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. r (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. h, .� ---•:r^..vivo-:a+w.s•ire...:.ss.w<-.•e.�,..aya7,,+.irfVl�'�►'•-#NY'1�'+M�.,.Mai^fi^.t:»'�r`�x�,..F:,..�..�ii.5a:.j� 45.+,+;a,1..a+,^97.R=.- �> '? b HOBBS 8 WAEN'm THE COMMONWEALTH,OF MASSACHUSETTS FORM 30 H&W t` BOARD OF HEALTH CITY/TOWN DEPARTMENT U M N SZ• Y }1 A N NA VAA <c ADDRESS TELEPHONE } Address �� 5 A)4.4, �17 "�xQnr��(�[.(Occupant �A74 Z..t.} °° N AV O ; Floor '""- Apar ment No. No.of Occupants No.of Habitable Rooms '�1 No.Sleeping Rooms L No.dwelling or rooming units" No.Stories I ` Name andaddress of owner P—a b d C-1 D T 4 rjo im 2A O Q• C-4 rl(2 W%6 j a N 0 '] -76 2- Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: f_ Drainage ' Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: I: ❑ B ❑ F ❑ M , Doors,Windows: Roof ` Gutters, Drains: 'i Walls: ` Foundation: , Chimney: 1 BASEMENT Gen.Sanitation; \ Dampness: -- Stairs: ' f - Li•htin =+ STRUCTURE INT - Hall,Stairw Hall, Floor,Wall,Ceiling: ,\ 1 Hall Lighting: i9 Hall Windows: HEATING --Chimneys: Central 19Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: I ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: 'k AMP: Gen.Cond. Distrib. Box.- Gen. Basement Wiring: / DWELLING UNIT /Ventil. L to . Outlets Walls Ceils.' Wind. Doors Floors Locks Kitchen Bathroom , Pantry, V .. Den Living Room Bedroom 1 , "y ( Bedroom 2 i` Bedroom 3 , Bedroom 4 - Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks-Flues--Vents,Safeties.- Kitchen Facilities Sink /i c Stove Bathing,Toilet Facil. Vent., P u�Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: 1, General Buildin 'Posted —To dS € PGS'rdO Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE y 4 OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE - AUTHORIZED INSPECTOR. (See Over). '+ "THIS INSPEC IN REPORT,IS SIGNED AND CERTIFIED UNDER THE PAINS AND SQ v PENALTIE PE INSPECTO ff G J tt TITLE �g4..17�'l ._ U -- r DATE O TIME 0 C/ P.M. A.M. ` THE NEXT SCHEDULED REINSPECTION = (/ i 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 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. TOWiv OF BARNSTABLE LOCATION 41 S 4,14NIViS AWAJ 1T 6 SEWAGE # 95-Ledo i � VILLAGE RA2N�`�i4t L ASSESSOR'S MAP &LOT —222-60 INSTALLER'S NAME&PHONE NO. W L Kalk '775-8-776 SEPTIC TANK CAPACITY K 5 cY-tI 5�' LEACHING FACILITY: (type) IC-�C "f (size) _a x 4 K Coal NO.OF BEDROOMS 1 BUILDER OR OWNER �'C.AUZ r DC:A DD' E2— PERMTTDATE: 1I COMPLIANCE DATE: Id I-) Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 arfivi S Y3�rs4rah(F r�� Id J' E Md 1 Cr No. / Fee 3 0 .0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYtcatton for Ztgponl *pgtem Cow6tructton Vermtt Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 1415 Hyannis Rd R. Deadder Barnstable 25 Meadow Dr Shrewsb Installer's Name,Address,and Tel.No. Designer's Name, ddress and Tel.No. W.E. Robinson Septic Service P.O. Box 1089 Type of Building: Dwelling No.of Bedrooms 1 Garbage Grinder(n9 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 Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install 1 , 500 gal _tank, d—box and 60 ' leach—trench Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Application Disapproved for the following reasons Permit No. -,�" Date Issued ——————————————————————————— —————————— ��' _ .., yr,.iT K � .+.ka ...'N`__..�, r.:..+- �+ti+e#y•A-•ai.A6t'��a`'a"®'`f,�Y*�4��.,,.� .;n' .K`:s.*sl'�=rr�.r Yat�.`;P�,r+.s.-.s�roe. '.h4.i".�,�.,:a..r•-a,.f,,:$,yths!°�'. rx SDO y _ ' - Fee 3 0.0 0 II THE COMMONWEALTH OF,MASSACHUSETTS PUBLIC HEALTH DIVISION.-TOWN OF BARNSTABLE., MASSACHUSETTS . 01pplicatiou for Digool *pgtem Cou$truction Permit.. Application is hereby made for a Permit to Construct( )or Repair(k )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No: 1415 Hyannis Rd R. Deadder :Barnstable 25 Meadow Dr Installer's Name,Address,and Tel.No. Designer's Name, ddress and Tel No: W.E. Robinson SeIA-ic Service P.O. Box 1089 een1 Type.-.of Building: Dwelling No.of Bedrooms 1 Garbage Grinder(nq. Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures .pesign Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install 1 ,500, gal tank, d-box and 60 ' leach-trench 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 Environmetital Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed . - - - Date Application Approved by Application Disapproved for the following reasons : Permit No: Date Issued THE COMMONWEALTH OF MASSACHUSETTS I PUBLIC HEALTH DIVISION - BARNS TABLEsMASSA CHUSETTS k , Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed or repaired/replaced( X)on by W.E. Robinson Septc for R. Deadder ` as 1415 Hyannis Rd Barnstable has been constructed in accordance t with the provisions of Title 5 and the for Disposal System Construction Permit No. -- 0 dated Use of this system is conditioned on�compliance with the provisions set forth below: jf' V 7 ci +k. 1 No. o 0 Fee 30.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ligpo.5al *p.5tem Cow5tructiou Vermit Permission is hereby granted to W.E. Robinson Septic' to construct( )repair( x)an On-site Sewage System located at 1415 Hyannis Rd- Barnstable R-. Deadder and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and.the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: - `i Approved by CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, , , hereby certify that the application for disposal works construction permit signed by me dated ��"'�`" , concerning the property located at CZmeets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase inflow and/or change in use proposed , • There are no variances requested or needed. z a SIGNED: G DATE: � V LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF B BARNSTABLE NUMBER ses a certified lot plan, [Attach a sketch plan of the proposed system. Also�the licensed installer poses p p , this plan should be submitted]. J v � L J J