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Commonwealth of Massachusetts a// 0/3
Title 5 Official Inspection Form
4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
178 Annable Point Road
Property Address
P ?
Nancy Kean CJ
Owner Owner's Name r r,
information is
required for every Centerville Ma 02632 10/7/2019
page. CitytTown State Zip Code Date of Inspection r
r�
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information IL41 Sq
on the computer, Sean M. Janes
use only the tab
key to move your Name of Inspector
cursor do not
return
use the return _S.M.Jones Title V Septic Inspection key. Company Name
74 Beldan Lane
OEI Company Address
Centerville Ma 02632
Cityfrown State Zip Code
raw
774-248-4850 smjonestitle5 ct Dgmail.com, SI 4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10/7/2019
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP, The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note:This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
15insp.doc.rev:712612015 Title 5 Official Inspection form SubsLdscs Sewage Disposal System•Page 1 of 16
Commonwealth of Massachusetts `t
- - Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Keany
Owner Owner's Name
information is required for every Centerville Ma 02632 10/7/2019
page. City(Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System,Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The property located at 178 Annable Point Rd Centerville is served by a Title V septic system
consisting of a 1000 gallon septic tank, distribution box and 2 Flowdiffusers. The system was found to
be in proper working condition at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rem,712812018 Title 5 Official Inspection form;Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Keany
Owner Owners Name
information is required for every Centerville Ma 02632 10/7/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
2) System Conditionally Passes(cunt.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
ftsp.doc•rev.7/2612018- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
f
178 Annable Point Road
Property Address
Nancy Keany
Owner Owners(dame
Information is Centerville Ma 02632 10/7/2019
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system Is functioning In a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and sail absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
tSlnsp.doc•rev.MW2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 4 of 18
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Keany
Owner Owners Name
Information is required far every Centerville _. w..__._. � . Ma�._.__... 02632 IOM2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cons)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes If the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
dinap.doc•rev.7126/20l a Title 5 Official Ins=1an Form,Suhu,rtarF.,%wape MgMul System-Pap 5 d 18
c CommonweaKh of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Kean fy
Owner Owner's Name
Information Is Centerville Ma 02632 10/7/2019
required far every
page. City(rown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must Indicate"yes"or"no"for each of the following for aH inspections:
Yes No
❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on;
® ❑ Existing information, For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) (310 CMR 15.302(5))
15insp.doc-rev.7t28/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 6 of 18
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
IV-vv
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
LUPO
178 Annable Point Road
Property Address
Nancy Keany
Owner Owner's Name
information is required for every Centerville Ma 02632 10/7/2019
page. Cltyfrowrn state Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3----- Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
Description:
Number of current residents: -0 —
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes Z No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): -
Detail:
Sump pump? ❑ Yes ED No
Last date of occupancy: unknown
Date
t5insp.doc•rev.7►26=8 Us 5 official Inspection Form:Subsi dacs Sawage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
_ Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Keany
Owner Owner's Name
Information is Centerville Ma 02632 10/7/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): --
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes,discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: w-_ __.. ._......,_..._......................_......._..._....._......_
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
Now was quantity pumped determined?
Reason for pumping:
t5tnspAoe-rev.7d26W 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1 j 178 Annabie Point Road
Property Address
Nancy Keany
Owner Owners Name
information is Centerville Ma 02632 10/7/2019
required for every _ _._ ............._...---_.�.__.___...---,_�.__....�.,
page. Cltyrrown _ State Zip Code Date of Inspedion
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the i/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
system installed 1991, d-box replaced 10/4/2019 permit#2019-377
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints in good condition, no leakage, vented through roof.
l5anp.doc•rev.7r2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Kean
Owner Owner's Flame
information is Centerville Ma 02632 10/7/2019
required for every
n State Zip Code Date of Inspection
page. itWr ow
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below feet
grade:g feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons „ _ ___....__.......__...__... __._.
Sludge depth:
5"
Distance from top of sludge to bottom of outlet tee or baffle 3'
2"
Scum thickness _-----_....._..._._____.................
........__
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Opened covers and took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance.water level was even with outlet, tank was not leaking and was structurally sound.
t5htsp.doc-rev.7rM018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
r
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Keany
Owner owners Name
information is Centerville Ma 02632 10/7/2019
required for every
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
B. 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
t5et o,doc•rev 7128/2018 Tilla 5 Official Inspection Form:Subsurface Sewage Disposal System•Pogo 11 of 18
Commonwealth of Massachusetts
--- Title 5 Official Inspection Form
5. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Keany _
Owner Owner's Name
information is Centerville Ma 02632 10l7/2019
required far every _.._ _.�___..��,__....._........,..�..._.
page, Cltyfrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: - -- ---- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert off —
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.):
Distribution box was replaced permit#2019-377
t&rw,doc•rev.7IE812t118 Tillp S Of inl Incp Ohn Fnrw Siihcurtam Sowago Dicpocal Syclom•Pago 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 178 Annable Point Road
Property Address
Nancy Keany
Owner owner's Name
information is required far every Centerville Ma 02632 10/7/2019
.------
page. City/Town State Zip Code Date of inspection
D. System Information (cons)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2 Flowdiffusers
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: --
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
tlitim.doc-rev.712612016 Title 5 Official Inspection Form:Subsrface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Keany
Owner Owner's Name
Information is Centerville Ma 02632 10/7/2019_
required for every CityRbwn state Zip Code Date of Inspection
page.
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching facility was video inspected and found dry with no signs of past overloading.
12. 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
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
tftsp.doc rev.7/4 MIS We 5 Ottwyal Inspection Form:Subsurtace Sewage oisposai system•Pape 14 of 18
f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Keany
Owner owner's Name
information is required for every Centerville Ma 02632 10/7/2019 page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t"it"dot•rev.7t2$W 8 Title 5 Official Inspection Forms Subsurface Sewage Disposel System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Annabie Point Road
Property Address
Nan Keany
Owner owner's Name
information is Centerville Ma 02632 10/7/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5ftp.doc•rev.712MI8 Tftle 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy Keany
Owner Owner's Name
information is required for every Centerville Ma 02632 10/7/2019
---
page. Cityrrown State Zip Code Date of Inspection
D. System Information (font.)
15. Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 7
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:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using a laser transit it was determined that the bottom of the leaching facility is 4'+above the Lake
Wequaquet surface water elevation. See sketch page 18
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.eoc•rev.7rMO18 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Pap 17 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Annable Point Road
Property Address
Nancy KeanY
Owner Owner's Name
Information is Centerville Ma 02632 10/7/2019
required for every
page CityrTown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form Inclusive of:
® A. inspector Information., Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
F
1
t5insp.dac-rev.7/26/2018 Title 5 Official Inspection Forth:subsurface Sewage Disposal System•Page 18 or 18
6
No.ao ct Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppiication for Misposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair V5 Upgrade( ) Abandon( ) ❑Complete System individual Components
Location Address or Lot No. `")lr A n n,r%6t e_ P k Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel o Z Gw
Installer's Name,Address,and 1�.1.No. Designer's Name,Addressland Tel.No.
S' ® Ff-
Type of Building:
Dwelling No.of Bedrooms N 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 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 1 1 `j Qi t V 1\
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not lace the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date 16
Application Disapproved by Date
for the following reasons
Permit No. ® Date Issued
t`L i
No.
�2 C) !0( Fee
THE COMMONWEALTH OF MASACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application' for Disposal 6pstrm Construction Permit
1 t
Application f�qr a Permit to Construct( ) Repair V� Upgrade( ) Abandon( ) ❑Complete System �dividual Components
Location Address or Lot No. 1'> A Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel (� 9. 2 C
Installer's Name,Address,and Tel No. t f/� 1 Designer's Name;Address and Tel.No.
S o
Type of Building:
Dwelling No.of Bedrooms A— Lot Size sq.ft. Garbage Grinder( )
Other ` Type of Building t, No.of Persons Showers( ) Cafeteria( )
Other Fixtures 4j
Design Flow(min.required) A gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title _r
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date / GG k( it
Application Approved by Date — — D
Application Disapproved by f Date
for the following reasons
4
Permit No. � Date Issued 10
- -------------------------------------- ----------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
r Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(1�) Upgraded( )
Abandoned( )by
at���/��������j n����������?as been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.90(9—37�- dated G` —�
Installer Designer 1
#bedrooms Approved design flow gpd
The issuance of this pe it shall not be construed as a guarantee that the system won n as desi .ed.
Date p Inspector
------------------------------------------------ -
No. 019 — Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(/ Upgrade( ) Abandon( )
System located at ` =e
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. 2
j
Date � � Approved by
r
TOWN OF BARNSTABLE
-LOCATION V) 9 An ry,- Wc, ! 'd SEWAGE# c2a(q
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. Sc<-, s-'►
SEPTIC TANK CAPACITY [60 6 N I y, New H 16 D Q OX a :L C' d S
LEACHING FACILITY:(type) ( C\`N4ize)
NO.OF BEDROOMS
OWNER 1t`QG.P\C `y
PERMIT DATE:Itg � 1 ICI COMPLIANCE DATE: Ct
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within INJ
300 feet of leaching facility) Feet
FURNISHED BY ��
j ..
d3as �u
o 110
S loll
3 �
{ y
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date �C <<� 1 Time: In a" J Out
Owner V 4MC-V t eo*3 e- (048-5�3 1 Tenant V
Address 6L eZS2n VWWZM CA-5,,J Address 17
('�v�-�e✓ v''1�1�-AVM 04-(03-ZIfer2- � a. tea' (ate
Compliagee Remarks or
Regulation # Yes XN0 Recommendations
2. Kitchen Facilities Appmea:
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities f
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal �� 3
17.Temporary Housing
18. Driveway Width
19. Number of Tenants Observed
PART II rSv L
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms 7 Number of Vehicles Allowed (max)
Number of Persons Allowed (max) - j � 6(,��� n //
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
f - /
TOWN OF BARNSTABLE Approved- '00ho
BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
Date / �0/ Time: In Out ®1
Owner I IV v� (� Tenant V ACA Iv
Address Z 1 r/�}�`� LY' y Address
IF
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply /1�D 1/1 L����NS 6 5C-(zUt'0
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal 2� F q d 10
16. Sewage Disposal
17.Temporary Housing
18. Driveway Width
19. Number of Tenants Observed Ae
PART 11 2j� y 3 Z (' Z
37. Placarding of Condemned Dwelling; V `t
Removal of Occupants; Demolition
Number of Bedrooms —15 Number of Vehicles w (ma )
Number of Persons Allowed (max)
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
I
No..9 ^l...... Fps.. �.6.. ..........
TkiE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...Q-CA
al- --------------OF....... ...........................................
ApplirFa#ion for Uhipaii ai Workii Cnnnitrurtiun Frrutit
Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal
System at: /�_
................-----"'-•----1-� .....� ''cz-����..�.-«J -......--��..................-----------`--------.........-----------------....-----------
Location_Address or Lot No.
" f� __ 9_rjrja,1a lr.. :a-ult... w---d.................•........
Owner \ Address
Installer Address
U Type of Building _ Size Lot..... `��_ ......Sq. feet
Dwelling—No. of Bedrooms-----7h r c.i k•---._______•----__-----Expansion Attic (A/o) Garbage Grinder (Al-)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures ----------------------------•-•• .
W Design Flow...................................575__gallons per person per day. Total daily lflow.......................3_.3_0_--_-__gallons.
WSeptic T nk—Liquids apacitv:lOPoa.gallons Length_£ ..____ Width. -1....... Diameter._.-=77m... Depth�.' '�..
x Disposal —,.`�Io- -------w.,m..-- Width..../_.0......... Total Length----2,41
-------- Total leaching area---Z ......sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet-................... Total leaching area..................sq. ft.
Z Other Distribution box (K) Dosing tank ( ) f ,
'"' Percolation Test Results Performed .A_46.bl4.t.......... Date_?h�$%_£._I
4 Test Pit No. 1...... ...._..minutes per inch Depth of Test Pit......K./........ Depth to ground water..... ................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water .....
•---------------------------------- • . . .._.....-•---•••-•-........ ------•---•-•-----...........................
O Description of Soil.... ��--'--.i.4f?_ cths��._T.J._- _�5-- -R► Q�_= ..W` _._C0-16jaic-3-}.------ - -------
x TEPHENI
v.. .. �_�. Cl1Gc�.�c!s w•men cobs/rs, kr:d—.�xQ rd�t�.cr .��tnr�• -----
W t)/ G_1ri1c: C3
x C3 V 4�
U Nature of Repairs or Alterations—Answer when applicable-----------------------------•-___-____-_.--_______-___----- _3R?1.6 ?
.09 v�rv�
-----------------------------------------------------------------------------------------------------------------------------------------------------------------••. .. a
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac e .>a with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compli�e has been issu by the board of health.
V — s///?
;gned ..--...---/j/t 1�----------- ................................................... --- -------�............�.........
FD)1 F yo
Application Approved B - � '�L�% .pp Pp y ------ - --------------------------------------
Date
Application Disapproved for the following reasons' .............................................. ............................................................------- ---------------
------------------- --------------- -------------------- ---- --- - -- --------------------------........................................ ..............................
---------------- -- -- ..............
- -- ---- ----------------------------------------
Permit No. ------ -- � 6 �v �`�.
� C�-------- -- --- - -- Issued -- ---................�-------- �--------------
Date.........................
.� TOWN OF B RNSTA LE s
LOCATION I� SEWAGE # `����
VILLAGE - ^ - !�
ASSESSOR'S MAP & LOT—
t
' INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) at size) X�
NO. OF BEDROOMS 3 PRIVATE WELL. OR UBLIC ATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
��a r to
Y 1{/�JS v
TOWN OF BARNSTABLE
LOCATION /7 AVM'` . C / 7, / SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. /4/ �
SEPTIC TANK CAPACITY
1
LEACHING FACILITY:(type) l FIW5 5 (size)
NO. OF BEDROOMS PRIVATE WELL O PUBLI WATER
BUILDER OR OWNER U(--
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: ,, 9
VARIANCE GRANTED: Yes No T�
"�
_ ,
� a
�3 .. �
� 1
���
� �-�, �
��1 � ��
�� P,�
`._1 ��
a�
���, � : -�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
To.w.V..............._OF.......%1�'A..�/�TA Ic3.��...........................................
Appliration for DioVooal Works Tontrnrtion ramit
Application is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal
System at:
................__......--...................................................................... ----•-•-•••••-•---•--------•------•••••---••••-•--••------•---•-••----------••----•-..............
Location-Address or Lot No.
3e„? )1!_Irk-S-.......................................... . ......................... -----•----•-•-•--•------..............•...........
Owner I76 ' Anna -P6AddgssQOae.Q
(7] r
Installer CY`V I I(C Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.— _____.__ Expansion Attic ( ) ��rbp�e7Grinder ( )
1 tlrci:' j
p., Other—Type of Building ............................ No. of persons...................A/c, _ Showers ( ) — CafeteriaA )
Q' Other fixtures ..................................
W Design Flow.................................:5 ------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank D)tic%uiiddcapacity10-0 ._gallons Length&'.&':.__._ Width-4 to Diameter_---�cpepths!=a."...
x Disposal ...Twn.-_-. Width---/__Q........... Total Length... _......... Total leaching area.__-------sq. ft.
Seepage Pit No-----------_------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (X ) Dosing tank ( )
aPercolation Test Results Performed _,E.-!e/1f".6r Z............ Date./Jll�S%_
Test Pit No. I.....7.........minutes per inch Depth of Test Pit-----S'_........... Depth to ground water_ _ ............
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground -OF
a ------ - ---------
- -----•••...
Description of Soil... 'I-_a_74_-- -�s1ki�Ql.�-�J__-s�aS__}_ ��_ rr1�_.c.1 f �,J--�ra{able,p- ---- sTEPHIQN---
x
.y,5-..�,0.� �Yllcr�. 2el6f.-"i•/1'�'t CO�zb/ram__.��b.-.$ :. �e/ide�f.__ T ALLYN
V - !- 'AtI 54�1� y�ILSON y
W ---W /Smsstl_..S.fvr1r......-. . •• - - •- -•
ICI 3021T
U Nature of Repairs or Alterations—Answer when applicable...........................................................
-------•---------------------------------------------•------•-----------------------.......--•-•--•-----•------...------------•-----------------....••••----------...-• s•.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System ' actor ante with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed ----------------------------------------------------------------- -- -- ---- -- ------------- ----------------------------------------
Date
ApplicationApproved BY --------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------
Date
Application Disapproved for the following reafons: ...................... . .. ..................................................................... ........................
.......----- ............................................................. .... ................. .. ... .. ... .. . ................................ .......... ... ------------------------------
Date
PermitNo. ....... ............................................... .. Issued ....................................................---------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-7 !' ---�-------------- OF 61_36i� ---...-----------------------------
V�Prtifirate of (11antylinure
TIVS IS TO E TI Y, That the Individual Sewage Disposal System constructed 1/ or Repaired
g p Y ( ) p ( )
by ;� ......
.. .. �
at ...'L T"�C...............Installer `/..�.._ ��'QQQ 'L ............. .......................................................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as describe in
the application for Disposal Works Construction Permit No. ......... . - -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEd AS A GUARANTEE AT THE
SYSTEM WILL FUNJCTION SATISFACTORY.
DATE........ :f pOL
iEl GG► � �`���o .. -T
-------------------------------------------------- Inspector ..... -- - --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF................................_....................................................
No.••••••••-••............. FEE........................
Uiipoiial Marko Tonotr ion rrmit
Permission is hereby granted..............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
•----------------•---------•-------------------------------------------------•••-•-•-•._...---........._
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
LOCATION SEWAGE PERMIT NO.
VILLAGE
IN &TA LLER'S NAIVE & A0DRES.S
A&z �
IB UILDE R OR OLWNE
DA T E PERMIT ISSUED
DATE COMPLIANCE ISSUED
i �
I�/d
>
h� 310 CMR 10.99
Form 5 DEC)E File No I SE3-2005
`� CF THE T� (To be oroviaea by DEQEi
® ♦ Barnstable
City Town
Commonwealth
of Massachusetts : 31asrs•r11M applicant Childs
Y,ud ,,
1639.
Order of Conditions
Massachusetts Wetlands Protection Act D
G.L. c. 131 , §40 0
TOWN OF BARNSTABLE BY—LAWS, ARTICLE XXVII-
From Barnstable Conservation Commission
To James L. Childs Same
(Name of Applicant) (Name of property owner)
8 Forest Lane
Address Hingham, MA 02043 Address Samr,
This Order is issued and delivered as follows:
by hand delivery to applicant or representative on (date)
X by certified mail. return receipt requested on
October 11, 1989
•X (date
This project is located at Parcel #13 (178) Annabelle Point Road, Centerville, MA.
The property is recorded at the Registry of Deeds in Barnstable
Book 1429 Page 054
n/a
Certificate(if registered)
The Notice of Intent for this project was filed on_ July 1 7 , 1 q 8 q (date)
The public hearing was ciosea on
September 26 , 1989 (date)
Findings
The Barnstable Conse has reviewed the above-referenced Notice of
Intent and plans and has held a public hearing on the c-oject. Based on the information available to the r
Commission at this time. the Commission has deterr4iined that
the area on which the proposed work is to be done is significant to the following interests in accordance with
the Presumptions of Significance set forth in the regulations for each Area Subject to Protection Under the
Act(check as appropriate):
❑ Public water supply ® Flood control ❑ Land containing shellfish
❑ Private water supply ® Storm damage prevention N Fisheries
❑ Ground water supply Prevention of pollution 19 Protection of wildlife habitat
Filing Fee S
Refund Due S
Effective 8/1/89 5-1
I y r
ARTICLE 27 Only:
(� Public Trust Rights ❑ Agriculture . Erosion Control
❑ Aquaculture ® Recreational
❑ Historic Aesthetic
I
Therefore.theBarnstable Conservation-Commissio1111;,reby finds that the following conditions are
necessary, in accordance with the Performance Standards set forth in the regulations. to protect those inter-
ests checked above.The Sommiss inn orders that all work shall be performed
in accordance with said conditions and with the Notice of Intent referenced above. To the extent that the fol-
lowing conditions modify or differ from the plans. specifications or other proposals submitted with the Notice
of Intent.the conditions shall control.
General Conditions
1. Failure to comply with all conditions stated herein,and with all related statutes and other regulatory meas-
ures. shall be deemed cause to revoke or modify this Order.
2. This Order does not grant any property rights or any exclusive privileges: it does not authorize any injury
to private property or invasion of private rights.
3. This Order does not relieve the permittee or any other person of the necessity of complying with all
other applicable federal, state or local statutes.ordinances, by-laws or regulations.
4. The work authorized hereunder shall be completed within three years from the date of this Order unless.
either of the following apply:
a the work is a maintenance dredging project as provided for in the Act: or
(b) the time for completion has been extended to a specified date more than three years, but less than
five years, from the date of issuance and both that date and the special circumstances warranting
the extended time period are set forth in this Order.
5. This Order may be extended by the issuing authority for one or more periods of up to three years each
upon application to the issuing authority at least 30 days prior to the expiration date of the Order.
6. Any fill used in connection with this project shall be clean fill. containing no trash. refuse. rubbish or de-
bris. including but not limited to lumber, bricks. piaster. wire. lath, paper, cardboard.pipe, tires. ashes.
refrigerators, motor vehicles or parts of any of the foregoing.
7. No work shall be undertaken until all administrative appeal periods from this Order have elapsed or, if
such an appeal has been filed, until all proceedings before the Department have been completed.
S. No work shall be undertaken until the Final Order has been recorded in the Registry of Deeds or the Land
Court for the district in which the land is located. within the chain of title of the affected property. In the
case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name
of the owner of the land upon which the proposed work is to be done. In the case of registered land. the
Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which
the proposed work is to be done. The recording information shall be submitted to the Commission
on the form at the end of this Order prior to commencement of the worts.
9: A sign shall be displayed at the site not less than two square feet or more than three square feet in size _
bearing the words. "Massachusetts Department of Environmental Quality Engineering.
FiieNumber SE3-2005 -.
10. Where the Department of Environmental Quality Engineering is requested to make a determination and
to issue a Superseding Order,the Conservation Commission shall be a party to all agency proceedings
and hearings before the Department.
11. Upon completion of the work described herein. the applicant shall forthwith request in writing that a
Certificate of Compliance be issued stating that the work has been satisfactorily completed.
12. The work shall conform to the following plans and special conditions:
5-2
'
�
13. ) The work shall conform to the following plans and special
' conditions:
-
PLANS:
Title: Site/Septic Plan
Dated: September 11 , 1989, revised �~ 8
Signed and stamped by: Paul A. Levy, P. E.
On file with: The Barnstable Conservation Commission - SE3-2005
1. ) Within one month of receipt of this Order of Conditions and prior
to the commencement of any work approved herein, General Condition
number 8 (preceeding page) shall be complied with.
2. ) It is the responsibility of the applicant, owner and/or
successor(s) to ensure that all conditions of this Order are complied
with. The project engineer and contractors are to be provided with a
copy of this Order and referenced documents before the commencement of
construction.
3. ) Drywells or french drains shall be installed to , accomodate roof
runoff.
JHealth of the subsurface sewage disposal system.
5. ) Staked haybales and siltation fencing shall be set at the work |
�
limit prior to the start of work at the site and maintained throughout
construction.
6. ) All areas disturbed during construction shall be revegetated
immediately following completion of work at the site. No areas shall be
left unvegetated or unmulched for more than 30 days.
7. > The applicant shall submit a stamped plan and Notice of Intent
application for the existing, unapproved pier by October 30, 1989, or,
alternatively, shall remove the structure by the foregoing date.
Included on the plan and application shall be the existing, |
unauthorized groins located on the property.
| 8. ) A buffer strip 20' in width, planted in indigenous shrubbery 13' `-
/
on-center, minimum density) shall be planted immediately landward of
the bulkhead and `beach' - Prior to the onset of this work, the
applicant_ shall consult with the Conservation Department regarding
appropriate shrub species and densities. Said buffer is to serve the ,
purpose of preventing pollution (via surface runoff) of 'the Lake.
9. ) The applicant shall not remove any standing trees other than those
in areas proposed to be occupied by the house septic system or
driveway. Pursuant to this prohibition on cutting, the applicant shall
provide the Conservation Department with a diagram of all standing
�
|
'
- . . . .
�
trees. Deadline for receipt of the diagram is October 30, 1989.
,
10. > The lawn areas of the site shall be seeded in fescues. The
placement of sod is prohibited within Conservation Commission
Jurisdiction. Moreover, the applicant shall abstain from any use of
lawn care chemicals ( fertilizers, herbicides, pesticides) at the locus.
11 . ) The Conservation Commission, its employees, and its agents shall
have a right of entry to inspect for compliance with the provisions of
� the Order of Conditions.
� 12. > At the completion of work, or by the expiration of the present
( permit, General Condition number 12 shall be complied with.
�
�
_
'
|
�
�
/
�
�
`
'
'
�
|
�- -. -. __,.-- -...-- ---` — — ` '-- -------^'' --.' -'--`�---,-�-,---` — —'-`'--` ---~--'`--r -~`-`
Issued By Barnstable Conservation Co ssion
C
Signature(s)
This Order must be signed by a majority of the Conservation Commission.
On this llth day of October 1989 before me
personally appeared Douglas Bruce McHenry , to me known to be the
person described in and who executed the foregoing instrument and acknowledged that he/she executed the same
' as hisiher free act and deed.
October 28, 1994 n
A tary blic My commission expires U
The applicant.the owner,any person aggrieved by this Order,any owner of land abutting the land upon which the proposed
work is to be done or any ten residents of the city or town in which such land is located are hereby notified of their right
to request the Department of Environmental Quality Engineering to issue a Superseding Order, providing the request is
made by certified mail or hand delivery to the Department within ten days from the date of issuance of this Order. A copy
of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and the applicant.
Detach on Dotted Line and Submit to the Issuer of this Order Prior to Commencement of Work.
To Barnstable Conservation Commission (Issuing Authority)
PLEASE BE ADVISED THAT THE ORDER OF CONDITIONS FOR THE PROJECT AT
FILE NUMBER SE3-2005 HAS BEEN RECORDED AT THE
i
REGISTRY OF
i
ON (DATE)
If recorded land. the instrument number which identifies this transaction is
If registered land, the document number which identifies this transaction is
i
Signed
.applicant
_____________________ _________ _____________ ---,------------------- __ ___ "________._______ ___ __ _ , _� ___ _____ __-�-,�-�,.---�-.----��,-"---,�-.�-�,��- . __---.___________11------------ -, , _, ,_ - _,, , - I - I _ I I I I--- I I -- I I - I � -_. - �_._I_____ I I—— I-1-,-______
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