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HomeMy WebLinkAbout0019 BAY LANE - Health 19 BAY LANE A= 186—067 Centerville I i I /// S M EAD® Na 2-153LOR UPC 12534 swaad = • Moot M USA aq M• 0 3—3 1—20�B9 €tea 08 m 35c. DEED RESTRICTION WHEREAS, Veni Lemos(f/k/a Veni Prifti),Trustee of Lemos Prifti Realty Trust u/d/t dated November 16, 2001,recorded in Book 14507 Page 341, of 19 Bay Lane,Centerville,MA, is the owner of property located at 19 Bay Lane, Centerville,MA, shown as Lot B 1 on a plan recorded with the Barnstable County Registry of Deeds in Plan Book 496 ,Page77 ( "Property"); and WHEREAS, Veni Lemos,Trustee has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on the Property as a condition to obtaining an occupancy permit pursuant to Condition Number 2 in the Special Permit Decision issued by the Barnstable Zoning Board of Appeals in Appeal No. 2009-009 WHEREAS,the Town is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the Property be recorded with the Barnstable County Registry of Deeds by recording this document, NOW, THEREFORE, Veni Lemos, Trustee does hereby place the following restriction on the Property, which restriction shall run with the land and be binding upon all successors in title: Until such time as technology changes and the Barnstable Board of Health changes its regulations, or otherwise grants permission, any home constructed on the Property shall contain no more than 2 bedrooms. For title see deed recorded in Book 14507 Page 346. See also marriage certificate recorded in Book 2328 1 Page 189. Veni Lemos,Trustee, hereby certifies that she is the sole Trustee of the Lemos Prifti Realty Trust,that John A. Lemos died on 4/24/08 as evidenced by death certificate recorded in Book 23281 Page 190; that the Trust is in full force and effect and has not been amended or modified, and that she has full power and authority to execute this restriction. Executed as a sealed instrument day of �T�i , 2009. Veni Lemos (aka Veni Prifti),Trustee COMMONWEALTH OF MASSACHUSETTS Barnstable ss. On thi day o � ,2009, before me the undersigned notary public personally appeared Veni Lemos, u tee=Commission as.aforesaid proved to me through satisfactory evidence of identification which was erson whose name is signed on the preceding document and acknowledgt oluntarily for its stated purpose. D � ires: USA M.DeTOPA,Notary Public y Commission Expim March 5,2010 Commonwealth of Massachusetts Title 5 official Inspection Form' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .1,UVI Property Address us - to mation is G`Hner s Name mjulred for C v/ qVWY page. --ayl I own State Zip Code Gate of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. out A. General Information roans on the 1. Inspector: clay the tab keycur 1 to move your use1 117h- not uatlreturnName of Inspector e S°Y' TT Qn ���/ln�ie{r//�t� fP7C Company Name VQ Company Address ��, � Soufh�arr�ich _ C,tyr Town 0266 State 6049-,4(3 Zia. Code2—Za7,6 Si ��Sv Telephone Number License Number B. Certification 1 cartify that I have personally inspected the sewage disposal system.at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was perform. ed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: (Passes Q Conditionally Passes i ❑ Fails ❑ -Needs Further Evaluation by the Local Approving Authority • �d a O v Inspectors Signature Date The system inspector,shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shalt submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the,condttions 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. :yroo.00c•aeae i rile 5 Otedar Inspection Form:supeurfam Sewage 0,3Ooeal System-Pepe I d 1s Commonwealth of Massachusetts fu Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C A Property Address Owner Owners Namere /information is G'2.af/eA r1lt1/,e e ery p far _ Z /1 every page. Clty/Town State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 7Syste Passes: ve not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by I Board of Health,will pass. Answer yes, no or not determined (Y., N, NO) in the❑ 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. NO Explain: ❑ 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 ❑ obstruction is removed isb,sa.aoc•oaae Title 5 Cmdal Inspection Fort:Subauface Sews Dlepolal System•Pape 2 d 15 Commonwealth of Massachusetts Arm Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address o�N Tru f Owner Owners Name information is 'Ce:?AeAr/t Ile everyp for _ rl zb&Z _ 1Olo�/`d9 eveery page. - CityiTown State Zip Cdde . Cate of Inspection B. Certification (Cont.) B) System Conditionally Passes (cant.): ❑ distribution box is leveled or replaced NO Explain: The system -equired 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 Ej obstruction is removed NO Explain: 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 CBAR 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 I 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. tsnw.ao 0%W Tina 5 omoai inspecbm Fomr.suawmfam sevmg&0*09e1 system•Page 3 or 15 Commonwealth of Massachusetts Title 5 Official inspection Form ' Subsurfa ce ce Sewage Disposal System Form -Not for.Voluntary Assessments Property Address / ----- �.�'/7'Il9S ��'<t fir /�C?G.l�y �l'l•�S f Owner Owner s Name information is C�'���r/!`/�'. A�Q . required for te OZ& every page. Cityfrown State Zip Code Dat&of Inspection B. Certification (cont: C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 DER 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 Qi Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ d Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑N/A Liquid depth in cesspool is less than 6'below invert or available volume is less than V.day flow ❑ Q,' Required pumping more than 4 times in the last year NOT due to clogged or ^/ obstructed pipe(s). Number of times pumped: ❑ I� 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. Nnzadoa•08= Tine 5 Official Inspeafon Forth:Subsurface Sewage Disposal System•Page a or 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Pmperty A ress e rn©s Pr-i�fi l�z�ty Trust Owner Owner's Name/ r rntionyration is equLred for C�P/N 7` ' U every page. City/Town State Zip Cade Date or Inspection B. Certification (cons.) D) System Failure Criteria Applicable to All Systems (cant.): Yes No ❑ Q/ Any portion of a cesspool or privy is within a Zcne 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water suppiy well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DER 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.] QThe system is a cesspool serving a facility with a design low of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 C.MR 15.303. .herefore the system fails. The system-owner should contact the Board or 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 10,0o0 gpd to 15,000 gpd. For large systems, ycu 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 mapped Zone If of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or-answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. •� Title 5 Cnsoa,insoeman Form,Suosurface Sewage Oisocsat System•Page 5 of 15 J Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address L ei-nos Owner Owner's Name information V1 is required for (� Y1� fi'1� p Z b every page. Citylrown State Zip Code Date of Ins coon C. Checklist Check if the following have been done. You must indicate"yes"or"no'as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ [ Were any of the system,components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ ER Have large volumes of water been introduced to the system recently or as part of this inspection?. Q/ ❑ 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? Q� ❑ Was the site inspected for signs of break out? E ❑ Were all system components,.excluding the SAS, located on site? L ❑ 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)an the site has been determined based on: l� ❑ Existing information. For example, a plan at the Board of Health. Q/ ❑ 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)] 61nap.doc• Title 5 Official Inspectim Form;Subsurface S. ewege Disposal System•Pege 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments H &41 La e__ Property Address Owner - ,L e�,2 s A f-i ekall� I ras Owner's Namf¢ information is tP� required for _ Cepr iville o U.3Z /O/a//O,f every page- Crtyfrown State Zip Code Date of Ins pedian D. System Information R6sidential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes Q/No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ .Yes No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes `,i No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes C_;KNo Last date of occupancy: >'C5eo 71 D to 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: Last date of occupancy/use: Date Other(describe): rile 5 Cllloal Inapec4on Form;Suosufaor.SeMags Oisoasel System.-Page 7 d 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ,L emo Pry -'r' .o-a.ly-v Tr".sl Owner Owner's Nam information is required for G e r7 -e') y 1 ae every page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records:. / Source of information: sec 1 knDl Was system pumped as part of the inspection? ❑ Yes [?"".No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: I� 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) ❑ Tight tank.Attach a copy of the DEP approval. Cl Other(describe): Approximate age of all components, date installed(if known) and source of information: 7 7 Were sewage odors detected when arriving at the site? ❑ Yes No pep doa•O&M T'Ale 5 QHldei inspection Forth:subsurface sewage Disposal system•Page a or 15 Commonwealth of Massachusetts : P3Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Addre�� o ��� fir 7t�c<,s Owner Cwner's Name infirmafion is !J�� ��(`/� IF required for ` AM O Z43 Z I 0/cZ/�D g every page. Cltylrown State Zip Cade Oate of Inspection D. System Information (cant.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: cast iron L 4o PVC Q other(explain): Distance Tom private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): / 4O et/tC��.a1 C 4ed II�GLtGp Septic Tank (locate on site plan): Depth below grade: feet Material of construction: 2"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: ? X�',�%CAA 4�( Sludge depth: 13 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness less Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle ?" How were dimensions determined? ' Qsu d�0 S,4 ek • Me 5 OffCW In3osewn Form:Sutmufeee Se ws"Oiaposel System•Page 9 of 15 _ Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments is Property Address p / e 105 /i-1ffi 1 xT4 TrCCs:f Owner Owner's Nam�f information is CZ�7,4ei Vt ,/� required for l�/� A/1/9" every page. Cityfrown State ZipCode b' 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.):ok L � %-fie r vt Clilnc> .r�.rr11' GDP /,( Wl v e/a./ isrU2/27 s r r J- Ie4v Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ` concrete metal ❑ fiberglass polyethylene other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglasspolyethylene other(explain): lsmap.aoa•asroe rdle 5 Om"Inspecdo„Form-subsurface sewage aspa"System•page 10 at 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address L. en2.o 5 1-2r/�fi" Owner Ulvners Nam information is Celt. y���� required for l44 - D 3 Z /© 2,,1O 0 every page- Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity gallons _ Design glow: gallons per day. Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. [1 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? [I Yes ❑ No Distribution Sox(if present must be opened) (locate an 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.): ,6119 x C4, re, o��1 /(///¢ Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order. ❑ .Yes ❑ No ' Title 5 CMaal inspection Form:Submaiace Sewage oisposal system-Page tt of is Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntar/Assessments Property Address(/ Owner L�ryt os Pe; �,Zz f information is Owner's Name t Ti't�5 required for C e'1 vt 1(e- every page. C1lylTo in M� Z 6 State Zip Code Datebf Inspection D. System Information (cont.) 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: 5',4,5 z 0 C ccTt'a Type: leaching pits number, r ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ . overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): /` !Cr U 2 4a n 3.5 Alo Sigks &P.coe•omof rift 5 Offidw mspectfon Form:submalem Sewage DISDosq System-Pape 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface b urface Sewage Dis posal osal System Fo rm-Not for Voluntary Assessments 6 0-0- Property Address ✓'cc Owner Owner`s NaT e information is r�t'G!.7 t/I��P required for _ j — p 2.6'i2 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 laver Depth of scum layer Dimensions of cesspool Materials of construction J Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): /V//I- Privy(locate on site�plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.dot•Ot3108 Title 5 Cfficial Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address L e-mo s f? a Uy TrKst l Owner Owner's Name information is required forG�� V,lie 1 (jZ J o/Z!/p y every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. �.Y c 1n A j out- - 2� /3 — -- SWAM•osoe Title 5 0fridai inspection Form;SubMA12M Sewage OieQosal Syetem•Page 14 d 15 r A Commonwealth of Massachusetts Title 5 Official Inspection Form Su�urfface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Le w0 s 6-IPI Owner Owners Na e information is ' required for C e-0 ,zuI//f/ e /l/W 0 L(o3 Z /0/2//0c5 every page- city/Town State Zip Code Date of Inspection D. System Information (cont) . Site Exam: [�Check Slope [Surface water ['Check cellar ❑ Shallow wells �i Estimated depth to ground water. `eet Please indicate all methods used to determine the high ground water elevation: ❑� Obtained from system design pians on record If ^ecked, 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: 1''��I�- 1��2r a� t4`artD�Ir !Ne//'�N11MI ZQ - 7 �(.l��letl ,C3o Mb n o, 7,fl S 2Pa)ta, 'rt,)H tFdw.doe-08M - rdle 5 CRlaal Inspection Forth:subsurface Sewage Disposal Sy stem ystem•Page 15 of 15 LO=CATION SE PERMIT NO. V ILAGE INSTA LLER'S NAME & ADDRESS = v,nll B U I'L D E R OR OWNER C DATE PERMIT ISSUED 77 DATE COMPLIANCE ISSUED � � � --� . L- ( A Cr��A��" ,�� FIB THE COMMONWEALTH OF MASSACHUSETTS B ARD OF HEALTH 4/ kPoration for Uhipooal Worko Tonstrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at X* Address ------------------------------- Owner A Dwelling—No. of Bedrooms--- Garbage Grinder ( Seepage Pit No,,/,�AD- Diameter-----.............. Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) 1.4 The undersigned agrees to install the oforedescribed Individual Sewage Disposal System in accordance with the provisions of TI I1�LE 5of the State Sanitar Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en i ed h d of 4ao,,.e '-- _'-_---^-_'----Date ',. _ '- ..r - -'... . __-/-- -----'_---- ----- .......... Date ApplipaTi—da Disapproved for the following reasons:............................................................................................................. - ......................................................................................................................................................................................................... Permit Date ate ��� 6q . No........ ..... Fxs.._..`........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD F` HEALTH :.:..............OF....... _ -.mw� ... ....................... Appliration for .Dispos al Works Tnnstrnrtinn Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at ---------------- .. ......._...._...------------ Location_Addr s ; l .._ "`" s Owner Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms_______________________________Expansion Attic ( ). Garbage Grinder ( ) aOther—Type of Building ____________________________ No :of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .........................__ W Design Flow__________________________________________ allons per person per day. Total daily flow----.___.._.._.__.._________.._________._._gallons. WSeptic Tank—Liquid capacit gallons Length................ Width.................Diameter_-.----_________ Depth................ 1 x Disposal Trench No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No400_�_ Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed by___________________________________________________________ __ Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to, ground water........................ fi Test.Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ------------------ ........................................... O Description of Soil... U ----------- •---------------- ••----------- ---------------------•----•-•--•-•-----...------ ----------------- --------- -------------------•---------------------_...--•------------ -•---------------•--------- -..••-- --••-----•---------------------•---•---••-...----•------ -- p -- U Nature of Renairs or Alte ons Answer wh a licable , ._ !�„ W Agreement: Then undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT12 5 of the-State Sanitar Code: The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een ed th d of 1 th. Si --- - " -••••----•-•-- --•-------- ------------------- Application Approved,BY•---• - ------- ��' •�-----....-•- c Date Application Disapproved for the following reasons: ..........................................-------------------------------_---------- <. :., r 99 ;7 Date Permit No......................................................... Issued......k�: � 7 • -- ............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD ,F�H�EALTH ,fit OF Trrtifiratr of ft IMP' lianrr THIS IS TO fE Y, vidual Sewage Disposal System constructed ( ) or Repaired by---------- -------- --� ----- -I-- - at..-..� ip>- �-----��-- �l�_",.�+ .1 +!� r-------- t.`'�..', has been installed in accordance with the provisions of TITLE ,r of The State Sanitary C e �escr'b d .in, the application for Disposal Works Construction Permit No__ _____ �............... da.ted-._-. _._______------ ..... ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY i. DATE. s� 7.'.'.R` ° F s ,^� �� , ,y�4� inspector � ..4 w� M 9 zx 1"r�:;' x*` :s�:. v* °`.•, "t!T' — '0''': � .. •rn l�if#`�v�',r`'°` r"�"�?s'." �;d„ ,#F x THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............0F.._44W 444a [ No ..... ...... FEE-•--.j............... Disposal $ otrurtion rrnnt Permission is hereby gran _.___.04._,!w +._._._ _ _..9... to Construct �,eo R a> n I d vidual Sewage osal s em at No. - , . --."". ....... 04 .................... Street �} as shown on the application for Disposal Works Construction t No-...._ ___ _.__ ted___Q"__` ��"'__�f............: DATE.... __` _ _ ' .x Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS a,i aA� Q L0 AT i 44ION T� SEWAGE PERMIT Wd. 4 VILLAGE INSTALLER'S NAME & ADDRESS - I— E. Is N L&--st,)(L Lj vvteL- B UItDE R OR OWNER t-ti) L 6 A) DATE _: PERMI ISSUED DA COMPLIANCE ISSUED v 4 Lk �,j rsT Q®o - -- FAN _ _ F )cTTie L0 1-7 ATION SEWAGE PERMIT _-� VI LAGE I N S T A LLER'Scf� NAME & ADDRESS U, L, vyt BUILDER OR OWNER - -' Z) H2OL r DA T E PERMIT ISSUED i DAT �, COMPL"IANCE ISSUED J0ako663 --- i H- F!, ► I - �I ��j I_I -_H-� SIMF,aJ SEMPSPOJ 1r T 7 RYU g3 +� IF 9.,-; — o.c. HH l _ - W' jbu6%4 r WA•0-'A, I8' EAAhMA+A 091/6L-E Nvf t w,%OCA. S�B�kurMAatD xV 0 l /�I PN �'x�• L3 a F N } SCE 7 /v e.fl-ld 1 M W F►2 S erg al-*dale t �I'C Duwn rc r,��a o Zt STRUCI o. Swanson StrUCt ural,Inc. A ^cc 116 Forest Street Franklin,MA 02038 05 CU.S ro M !n n n�t rt t Ih(1rnL( • SCA q AMRW DRY: �'A R✓M DAfE: REVISE o-y-o� 1 .'f .SIG4WA! 1nA(O1vE-- JZ NJON S'nSr-7% <7lE DRAWING NU.RER a i j ! ( I sAe c SIM� Pilo" C516 Imo _ �8 rill I� µpv SDS _ �It0u6:SDSts j �-- ------ --- - - - __—_'-- _4 _.... . f 1 --hov 2.4 SO 4 S ---- — —--- 1 x o rRp¢•ti0 1to0 r . -- —--- — s�9"x3%O ALL ttOk9AD P,06 �T 1V. �;. 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G�/ILDou:- ?�R/��._ -,Q!';—yGt�`>`�U,c:�-- .n.o�-r../1.�Yc• .rc Df. -. GtJ/�.!5 4Y10 — �- 3°x0 col la 'a S TF a .7_. ............ - . Prue Fu - — D abxEB cc c r GSc r E e�V 3 oZ _ �No.3533a G -cN�as ss - l o _ � s ------ _ _...... - t�. LnCCI 9�. 9� g O PARCEL B Assessors Map 186 - P 22,36.0 S.F. Parcel 67 0.51 Ac.± PROPOSED 9/ 2 ADDITION _ 8 212 N N �O N C; Ul cp (J N cv o A ' p 4 9 •3 .-► .� c (V N EXISTING �o o v 1-13 �- -_-- WOODFRAME PROPOSED -- HOUSE ADDITION wIg O �l Z r i w O O . O N ' PLAN REFERENCE: PI. Bk. 69 Pg. 37 o DEED REFERENCE: Bk. 14507 Pg. 37 2a •70' W RG ■per= 941 MAIN STREET., SO . HARWICH . mMA 02661 432-2878 CERTIFIED PL 0 T PLAN IN CEN TER VILLE MA l cerflfy that the bullding on this lot is located as shown �P above and Is not located wl thin a Flood hazard area . 19 BAY L A NE _ CEN TER V I L L E MA PROJECT : 08 - 144 ISCALE : 1 JO_JDATE : 1017108